Health Information Management

Help establish the foundation for a comprehensive review of procedure data

JustCoding News: Outpatient, May 5, 2010

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by Lolita M. Jones, RHIA, CCS

The technical nature of the CPT® coding system can be very challenging for coding specialists, and even more challenging for HIM professionals who perform coding compliance and data quality reviews of outpatient medical records. However, HIM professionals can use coding edits and guidelines to target and analyze their coding reviews.

During this time of continued growth in outpatient surgery, HIM professionals cannot stress enough the importance of accurate and comprehensive outpatient procedure data. As of July 1, 1987, CMS has required hospitals to use the AMA’s CPT coding system to report outpatient procedures rendered to Medicare patients in all hospital outpatient settings (e.g., ambulatory surgery units, emergency rooms, clinics).

CPT code descriptions, notes, and guidelines, as well as Medicare’s outpatient code editor (OCE) provide a wealth of information that HIM professionals can use to analyze the accuracy of coded data. (Note: Contact the National Technical Information Service at 800/553-6847 for a copy of the Medicare OCE editor software.)

Consider the following tips that can help lay the foundation for an accurate and comprehensive outpatient procedure data quality review:

  • Note code edits and guidelines: Many of the audit tips below are based on specific guidelines inherent in code descriptions, the AMA’s CPT coding conventions, or coding guidelines the AMA has addressed in its CPT Assistant newsletter.
  • Consider coding analysis recommended action: I have provided recommendations below for how reviewers can analyze charts or claims data to determine whether edits have been violated.
  • Be aware of APC compliance and reimbursement issues: For each code, note the corresponding 2010 hospital payment rate to help you measure the risk or opportunity under the Medicare ambulatory payment classification (APC) methodology.

Pain management injections

The following APC audit tips and CPT coding edits are based on official guidelines from the AMA, CMS, and physician advisors who have performed postoperative pain management injections. First, let’s look at applicable CPT codes and their descriptions:

  • 20600 (arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes])
  • 20605 (arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa])
  • 20610 (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa])
  • 64400–64450 (injection anesthetic agent, spinal)

Code edits and guidelines

When physicians administer general anesthesia and perform pain management injections to provide postoperative analgesia, the injections are separate and distinct services for which you would report the appropriate code(s). It is immaterial whether the block procedure (e.g., insertion of catheter, injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure, according to CPT Assistant October 2001.

On the other hand, when the physician uses the block procedure primarily for the anesthesia itself, coders should not report the block/injection procedure, according to this same CPT Assistant. In a combined epidural/general anesthetic, coders should not separately report the block.

Coders should not report code 20610 for knee joint postoperative pain management injection when the physician performs this concurrent with another intra-articular procedure (e.g., knee arthroscopy), according to CPT Assistant December 2007. However, when the physician performs the pain management joint injection at an anatomic site other than that of the knee arthroscopy, coders may report the appropriate code from the 20600–20610 series with modifier -59 (distinct procedural service).

Coding analysis recommendations

Verify that documentation to support the reported pain management injection codes reflects that the physician performed the injection specifically for postoperative pain control/management.

APC compliance and reimbursement

During a review, ensure that coders reported the postoperative pain management injection and generated a separate APC payment when supported by the medical record documentation. Note the following codes, descriptions, APCs, and 2010 hospital rates:

  • 20600 (drainage/injection, joint/bursa): 0204, $172.28
  • 20605 (drainage/injection, joint/bursa): 0204, $172.28
  • 20610 (drainage/injection, joint/bursa): 0204, $172.28
  • 64415 (nerve block injection, brachial plexus): 0206, $250.89

Gastrointestinal submucosal injections

Consider also submucosal injections of gastrointestinal (GI) lesions. Note the following CPT codes:

  • 43201 (esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance)
  • 43236 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance)
  • 45335 (sigmoidoscopy, flexible; with directed submucosal injection(s), any substance)
  • 45381 (colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance)

Code edits and guidelines

Codes have been added to the GI endoscopy section for directed submucosal injection(s) of any substance, according to CPT Changes 2003: An Insider’s View. Examples of possible submucosal substances that physicians may inject include botulinum toxin, saline, corticosteroid solutions, and India ink, which permits marking of a lesion, allowing easier surgical or endoscopic identification of the involved segment of the GI tract in the future.

In unusual cases, the physician may indicate in the procedure report that through an endoscope (e.g., colonoscope) he or she injected a polyp with saline (i.e., lifted) the polyp prior to removal by another technique. In other cases, physicians may perform an injection to tattoo an area with India ink for identification during a subsequent procedure or during surgery. In both of these cases, coders should report a submucosal injection code in addition to any other therapeutic procedure, according to CPT Assistant January 2004.

Documentation in procedure reports may also describe an injection in conjunction with attempts to control spontaneous bleeding resulting from diverticulosis, angiodysplasia, or prior session interventions, for example. It’s appropriate to report code 45382 (colonoscopy with control of bleeding) for this injection instead of code 45381, according to information included in CPT Assistant January 2004 and the CPT 2005 Coding Symposium “Questions and Answers,” which the AMA presented in November 2004.

Coding analysis recommended action

Verify that medical record documentation supports submucosal injection codes: the injection of Botox®, corticosteroids, saline, the lifting of a lesion, or the tattooing of a lesion with India ink.

APC compliance and reimbursement issue

Consider the potential financial implications that can result from incorrect CPT code assignment or the generation of an inappropriate APC payment when documentation does not support a submucosal injection code. Note the following codes, descriptions, APCs, and 2010 hospital rates:

  • 43201 (esophagoscopy with submucosal injection): 0141, $589.55
  • 43236 (esophagoscopy GI with submucosal injection): 0141, $589.55
  • 45335 (sigmoidoscopy with submucosal injection): 0146, $389.25
  • 45381 (colonoscopy with submucosal injection): 0143, $613.74

The data quality review process doesn’t end with the analysis of the cases. In the January 31, 2005 Federal Register, “OIG Supplemental Compliance Program Guidance for Hospital,” the Office of Inspector General (OIG) stated that hospitals should develop an effective corrective action plan (CAP) that takes into account the root cause of any identified coding violation(s). In addition, hospitals should conduct periodic follow-up reviews of cases involving the problem areas to verify that the CAP eliminated the coding violation(s).

Editor’s note: Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services in Fort Washington, MD. Her Web site is

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