Health Information Management

Build a base for comprehensive review of procedure data

JustCoding News: Outpatient, June 30, 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 health information management (HIM) professionals performing coding compliance and data quality reviews of outpatient medical records. However, HIM professionals can use several edits based on official resources, to target, analyze, and support their outpatient coding reviews.

I cannot stress enough the importance of accurate and comprehensive outpatient procedure data during this time of continued growth in outpatient surgery. Since 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).

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

Many of the audit tips I provide are based on specific official guidelines inherent in the code’s description, the AMA’s CPT coding conventions, or in CPT coding guidelines listed in the AMA’s CPT Assistant.

For each code edit, I include a recommendation for how the reviewer can analyze the chart or claims data to determine whether the edit has in fact been violated. The data quality reviewer should always document the source for each CPT code edit (e.g., specific CPT coding notes or guidelines, AMA guidance published in the CPT Assistant).

Implant removal

CPT codes 20670 and 20680 are available to report implant removal. The AMA updated its implant removal guidelines in the June 2009 CPT Assistant.

Removal of deep implant code 20680 has a unit of service that is reported only once, provided the original injury is located at one site, regardless of the number of screws, plates, rods, or incisions (e.g., the removal of a single implant system via “stab” or multiple incisions [e.g., intramedullary (IM) nail and several locking bolts]).

Coders may report code 20680 multiple times only when the physician performs hardware removal for another fracture in a different anatomical site unrelated to the first fracture (e.g., ankle and humerus). In these circumstances, append modifier -59 (distinct procedural service) to subsequent uses of the code.

For example, when a physician removes two different and noncontiguous implants from two different bones or two different (noncontiguous) sites on the same bone using multiple incisions, report either CPT codes 20680 and 20680-59 or CPT codes 20670 and 20670-59.

For plate and screw system removal, recognize that a physician can remove the plate and all of its associated screws through one long extensile incision. Alternatively, a physician can remove the plate and some screws through a smaller, less invasive incision, with the remaining screws being removed through smaller stab incisions. In either instance, report code 20680 only once.

IM nail systems (i.e., nail and interlocking screws) cannot be removed through one extensile incision, but physicians routinely remove them through a larger incision for IM nail removal and one or more smaller incisions to remove one or more interlocking screws. Therefore, report code 20680 only once for the removal of the IM nail and any or all of the interlocking screws when performed on the same day by the same physician.

Report code 20680 once for each bone when removing internal fixation of healing fractures of “both bones” (radius and ulna) of the forearm when each bone is treated with separate plates and screws. If the physician removes the plate and screw system from the ulna at the same session as the radius, report code 20680-59. Removal of any and all screws used for each fixation system (i.e., one plate and its associated screws) is part of the service of the plate removal.

Verify that any case reported with multiple units of 20670 and/or 20680 contains documentation that the physician performed the hardware removal for another fracture in a different anatomical site unrelated to the first fracture (e.g., ankle and humerus).

Multiple turbinate removal techniques

According to the AMA’s December 2004 CPT Assistant, do not report code 30930 with submucous resection code 30140 when the physician performs the procedures on the same turbinate.

Verify that codes 30930 and 30140—when reported on the same case—do not classify procedures performed on the same turbinate. For example, if the operating room report documents that code 30930 classifies the left inferior turbinate surgery and code 30140 classifies the right inferior turbinate surgery, then both codes are appropriate.

Any case reported with codes 30930-50 and 30140-50 is inappropriate because such coding indicates that the physician used fracture and submucous resection techniques on both inferior turbinates, which violates the CPT coding guidelines.

Stab phlebectomy

Stab phlebectomy involves multiple incisions, and code assignment is based upon the number of stab incisions.

Report code 37765 for 10–20 incisions and code 37766 for more than 20 incisions.

When there are fewer than 10 incisions, report code 37799. Per the AMA’s August 2004 CPT Assistant, it is inappropriate to report code 37765 with modifier -52 (reduced services) when the physician makes fewer than 10 incisions.

Bilateral urinary procedures

The following guidelines are based on information published in the AMA’s May 2001, September 2001, and October 2001 CPT Assistant newsletters. Coders should not append modifier -50 to the following cystourethroscopy codes and transuretheral surgery codes, as they are inherently bilateral procedures:

  • 52000
  • 52010
  • 52204–52285
  • 52305–52318

These codes contain the language “unilateral or bilateral” in the code descriptor, so coders should not append modifier -50 to the following cystourethroscopy codes:

  • 52290
  • 52300
  • 52301

Physicians most often perform the following cystourethroscopy procedures unilaterally. To identify the additional work required when the physician performs these procedures bilaterally, coders should append modifier -50 to one of the following procedure codes:

  • 52005
  • 52007
  • 52320–52355

Code 52005 identifies a singular (unilateral) ureteral catheterization by use of the language “with ureteral catheterization.” Thus, coders should append modifier -50 with this code if the physician performs a cystoscopy with bilateral ureteral catheterization.

When the physician places bilateral ureteral stents, coders should add modifier -50 (bilateral procedure) to code 52332.

Coders may append modifier -50 to the following codes when the physician performs the procedure bilaterally:

  • 50020–50290 Kidney (incision and excision categories)
  • 50390–50405 Kidney (introduction and repair categories)
  • 50541–50548 Kidney (laparoscopy)
  • 50551–50580 Kidney (endoscopy)
  • 50590 Kidney (lithotripsy)
  • 50605–50630 Ureter (incision)
  • 50740–50760 Ureter (repair)
  • 50780–50840 Ureter (repair)
  • 50860–50940 Ureter (repair)
  • 50945–50980 Ureter (laparoscopic and endoscopic categories)
  • 52005–52010 Endoscopy-cystoscopy, urethroscopy and cystourethroscopy
  • 52320–52355 Ureter and pelvis
  • 54500–54560 Testes (excision and exploration)
  • 54640–54680 Testes (repair)
  • 54690–54692 Testes (laparoscopy)
  • 54700–54840 Epididymis (incision and excision)
  • 55400–Vas deferens (repair)
  • 55500–55550 Spermatic cord (excision and laparoscopy categories)

Verify that bilateral urology procedures are coded appropriately and modifier -50 is appended if required.

Ensure the appropriate CPT coding and/or generation of the appropriate Ambulatory Payment Classification (APC) payment when the physician performs bilateral urology procedures. If bilateral procedure modifier -50 is required and reported (e.g., 52332-50), Medicare will pay 150% of the APC rate for the code.

Editor’s note: Jones is the principal of Lolita M. Jones Consulting Services in Fort Washington, MD. Her website is www.EZMedEd.com.

This article was originally published in the June issue of Briefings on APCs. E-mail your questions to Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.



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