Diagnosis from triage sheets

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Nobody that I work with seems to know the answer to this question. We do both diagnostic and interventional radiology. The problem is with patients who come in through the ER. I don't know if it is because everyone is in a 'state of emergency,' but we never have an order on file for these folks. What's worse, the indications line is usually no help at all in coming up with a primary diagnosis. It might say something like 'chest x-ray,' or something else that is not code-able. It is my impression that they are just doing a chest x-ray 'just in case.' Anyway, finally I arrive at the question: Is it appropriate, kosher or cricket to take signs and symptoms from the triage sheet to use as a primary DX when you have absolutely nothing else to code? The triage sheet is the nearest thing we have to an order. Is this the sort of thing we could get 'dinged' for in an audit?

Diagnosis from triage sheets

newly certified coder

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newly certified coder

Moving, looking for remote possible

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Hi, we are making a plan to move from CT to Louisiana in April. I have had my CPC since 2006. Currently been in a temp position for almost 2 years doing abstracting because there wasn't much out there to choose from. Anyways, does anyone know of any good coding/billing/abstracting jobs that are either remote or in the area of St. Mary, St. Martin, Assumption, Terrebone area of Louisiana? I'm moving with family to be closer to more family but I am not too familiar with what's in the area. Thanks!

Moving, looking for remote possible

PCP treating pt for medical condition while in Psych facility

We have a PCP who visits patients who are in a Psych treatment facility. My Dr is treating the patient for typical PCP stuff, ie hypertnesion, esophageal reflux, hyperlipidemia....He often bills a 99223, which Medicare has been requesting medical records on....What is the fine line between providing medical records to substantiate his claim vs. crossing the line w/ providing documentation to insurance about patient in psych setting? Often times the patient's HPI is psych related, but Dr is seeing them for other things besides psych....I am thinking that my Dr's HPI should only be related to what he is seeing the patient for, am I wrong? Where can I find guidelines related to this?

Thanks

PCP treating pt for medical condition while in Psych facility

Fistulagram coding assistance needed

This is what I came up with for this procedure:

36147, 36148, 36870, 37224

Would be grateful for any input or what I have missed.

PROCEDURE PERFORMED:

1. Fistulogram with dual access towards the inflow and the outflow of the fistula.

2. Pulse/spray administration of thrombolytic therapy for complete thrombosed AV graft.

3. AngioJet mediated thrombectomy before and after pulse/spray administration.

4. Angioplasty, extensive, of the inflow, of the arterial anastomosis throughout the graft, as well as at the level of the graft into the venous anastomosis.

5. Separate right femoral venous access and crossover into the left iliac artery and selective

angiogram of the left internal iliac into common femoral artery to identify the iliac stenosis.

INDICATION FOR THE PROCEDURE:

Patient with end stage renal disease on dialysis. After dialysis had developed complete thrombosis of AV graft in left thigh. It was a femoral arterial to venous sheath.

Informed consent was obtained from the patient after detailed description of risks and benefits. Patient was brought to the Catheterization Lab, prepped and draped in a sterile fashion. Following this, access was initially obtained towards the outflow of the AV graft and gentle injection showed extensive amount of thrombus towards the AV graft. Next, a short #6 French sheath was placed and a glidewire was used to cross into the venous system and gentle balloon dilatation using a 5 x 40 Mustang was performed to open up the outflow of the fistula. Next, AngioJet was used to thrombectomize the fistula first and after multiple runs, approximately 6 mg of TPA was pulse/sprayed into the graft and left to marinate for some time.

In the meantime, access was obtained towards the inflow of the fistula and using multiple wires it was not possible to cross across the AV junction. There was a very high grade stenosis or obstruction and it was not very clear where the AV junction was. Therefore, at this time,

contralateral femoral access was obtained and an IM catheter was used to go up and over and the head of the AV anastomosis was defined using multiple projections and multiple injections. Next, after a lot of difficulty, a PT wire was passed through the AV anastomosis into the external iliac artery. This was then swapped out for a standard J-wire and at this time, AngioJet mediated thrombectomy was performed on the inflow and pulse/spray was administered. Following this, pulse/spray thrombectomy was again performed in the outflow and the outflow now was widely open. There was some amount of thrombus material around the access site but most of the graft was widely patent.

Next, multiple injections showed that there was a 90% inflow stenosis at the level of the AV anastomosis. 6 x 40 Mustang balloon was used at high pressure to dilate this region. Following this, multiple images were obtained and showed that there was residual persistent stenosis and

therefore, a 6 x 40 balloon was again used to dilate at high pressure for over 2 1/2 minutes. At this point, the stenosis appeared to be less but there was still a residual stenosis at the AV junction, but this now appeared to be more in the 50% range and it was right at the anastomotic

segment. At this time, there was some irregularity in the outflow, particularly at the needle puncture site, and this site was dilated using a 6 x 100 balloon. The outflow was also dilated using the 6 x 100 balloon to improve flow through the fistula.

At the end of the procedure, there was excellent flow through the graft and both the sheaths were removed a purse-string suture was applied with hemostasis. The right femoral arterial sheath was also removed and hemostasis obtained.

The patient tolerated the procedure well and will be transferred to dialysis in a stable condition.

OVERALL CONCLUSIONS:

1. This was a complex intervention with multiple exchanges as well as multiple passes.

2. Complete thrombosis of the AV graft.

3. High grade inflow stenosis at the arterial to graft anastomosis.

4. Pulse/spray thrombolysis and thrombectomy of the entire graft.

5. Multiple inflations including the inflow, outflow, as well as the graft.

Fistulagram coding assistance needed

Observation Based on Counseling

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Is an Observation code billable based on counseling/co-ordination of Care? I don't get these very often and I cannot find it addressed. Provider has made a time statement and it is plausable in the scenario due to her diagnosis, however I do not know if it is allowed. He does need meet level without it.

Tricia D.

__________________

Tricia Didier, RHIT, CPC, CCS-P, CHONC

Observation Based on Counseling

Nephrology

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Nephrology

Modifier 59

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I have a provider that is doing a nebulizer demo. The billing company says that modifier 59 needs to be added so that it won't get bundled into the E/M. By the definition of 59 it doesn't seem that it would be appropriate to add to this service. Has anyone ever heard of this or any thoughts if this is appropriate?

Modifier 59

ultra sound denial with Medicare

We sent the appeal with a copy of the ultra sound picture along with all corresponding notes including the surgery notes.

Medicare came back with the following denial:

? The record is lacking documentation that the failure of the initial attempt at the knee joint injection where the provider is unable to aspirate any fluid or that the patients knee size prohibits the providers ability to inject the knee without the ultrasonic guidance.? The description of the knee does not support the need for the ultrasound 76942-R.?

However, they paid the other 2 ultra sound guidance on the same patient which were sent with the same notes.

Help please! Not sure how to proceed from here. Any ideas/suggestions?

Peggy

ultra sound denial with Medicare

Punch biopsy or Punch excision

I work for a pathology lab. We are being asked to call specimens a punch excision instead of a punch biopsy to correlate with the client's verbiage so they can code for an excision versus a biopsy. To meet the criteria of being a skin excision, the CPT book says, "An excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed."

Our pathologists sometimes do not see the subcutaneous fat that proves the excision/biopsy is through the dermis, thus the criteria for "excision" is not objectively met. However, the client's intent is to go through the dermis and, sometimes, the fat does not want to hang on as well with a punch procedure as with a scalpel procedure.

QUESTION: Does my pathologist need to specify whether or not there is subcutaneous tissue on his microscopic exam to prove that the specimen is an excision?

Punch biopsy or Punch excision

Which books: Buck or AAPC?

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Which coding books do you-all prefer and use in your office? I am a relatively new coder, I code for my clinic and the hospital the clinic is affiliated with, and I do not use the AAPC ICD-9 nor the AAPC CPT book; I use the books that I had in my coding classes--updated of course. In fact, when the boss asked what books to order, all of the coders I work with chose the same book, which incidentally was the same kind we had all used in our classes. (We all graduated from the same program, different years.) If you have used both, do you prefer one over the other and why? I confess, I have never even seen the inside of the AAPC books, but since they are AAPC, which is my professional organization, I wonder if they might be better than the ones I use. Comments?

Which books: Buck or AAPC?

proper billing with units and bilat modifier 50

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proper billing with units and bilat modifier 50

Multiple Hernia repairs

Can someone please give me some assistance!!!!?

A vertical incision was made directly over the most prominent recurrent incisional hernia. Incision was carried down through the subcutaneous fatty tissues to the hernia sac. The hernia sac was circumferentially dissected out and during the course of dissection a piece of old mesh was encountered and this too was dissected away from its fascial attachments. The hernia sac and piece of mesh were passed of to Pathology. A fresh fascial edge had been created. Examination of the abdominal cavity demonstrated three upper abdominal hernias. At least one of these was an incisional hernia. The mid abdomen was palpated and there was an umbilical hernia sac also identified. The further most superior had a fairly wide fascial bridge between it and the other hernias, threfore, the upper abdomen hernia was fixed seperately. The lower three hernias and the umbilical hernia was very narrow, therefore the fascial bridge was taken down. There were five hernias total that were repaired via two seperate incisions. The one that was furthermost superior just below the xiphoid process was through a prior laproscopic site. A transverse incision was made directly over this hernia site and carried down through the subcutaneous fat to the hernia sac. I could palpate the fascial defect intrabdominally. The hernia sac was pushed through and amputated. A small Ventralex patch was placed in this fascial defect, which was closed with interrupted 2-0 Prolene sutures incorporating the Marlex straps in the closure for fixation. Therefore, the hernia was completely closed and completely covered Ventralex patch. The Marlex straps were cut flush with the surface of the fascia. The subcutaneous fat was approximated with a running 3-0 vicryl suture. The skin itself was closed in running subticular fashion using 3-0 Vicryl suture. Dermabond was applied.

Attention was directed back towards the large recurrent incisional hernia. As mentioned above, the fascial bridge between this recurrent incisional hernia and the umbilical hernia was taken down with electrocautery, and the two smaller upper hernias had the hernia sacs resected. An approximately 14 cm greatest diameter oval Ventrio mesh was selected and placed in the fascial defect, which covered the entire length of the incisional including the two upper smaller hernias. This was anchored at the 12 o'clock and 6 o'clock position with a #1 Novafil suture. The fascia was separated from the overlying subcutaneous fat circumferentially utilizing electrocautery back approximately 5 cm on each side. The patch was then anchored to the periphery of the abdominal wall with at least three #1 Novafil sutures on each side. This nicely covered the hernia defect and there was enough laxity in the fascia to reapproximate the midline fascia over the mesh with two separate double strand 0 Novafil sutures starting in the superior and inferior aspect of the would and running these to the midpoint where they were tied. The closure incorporated the underlying mesh withing the closure to obliterate dead space. The overlying subcutaneous fat was then approximated with running 2-0 Vicryl suture, which was tacked down to the underlying fascia intermittently to obliterate dead space. The umbilicus had been tacked down to the underlying fascia with a singe 2-0 Vicryl suture. The skine was closed with surgical staples.

Multiple Hernia repairs

[unable to retrieve full-text content]

Pain Clinic Owned DME Company

I currently work for a pain management clinic that owns it's own DME company. When appropriate, providers write prescriptions for DME items such as tens units, back and knee braces and cervical pumps however they do sell other items such as Biofreeze, pillows and ice packs that don't require a prescription. The DME company does not service anyone else other patients then the pain management patients. They are not open to the public and don't advertise as an operating company. The DME company is not located in a separate facility, it is in a room at the pain clinic.

Does this type of business go against the Stark law? Or is this a legit way to run a DME company? I have concerns that because the pain management clinic has a financial interest in the DME company and that they are not servicing any other patients that this is not legal. Am I incorrect?

Any help or insight would be helpful!

Pain Clinic Owned DME Company

coding osteotomies

I am new at coding feet and I need help coding the following procedures:

Proximal first metatarsal osteotomy, RT foot

Distal soft tissue release, RT foot

Akin osteotomy, RT foot

Weil Osteotomy, 2nd and 3rd metarsal

The doctor wants them all coded separately and I do not agree with him.

I dont need help with the dx coding, was just provding for more info.

(DX:metatarsal primus varus rt foot, hallux valgus rt foot, hallux interphalgeus, and metarsalgia 2nd and 3rd metatarsal)

Any input would be greatly appreciated

coding osteotomies

Medi-Cal confusion

hello, looking for an answer to:

If a patient has Medicare and Medi-Cal as the secondary and she sees a provider that is a Medicare participant but NOT a Medi-Cal participant, can the provider bill the patient for the remaining 20% that Medi-Cal would pay if the provider was a participant? or is that against the law in California?

Thank you in advance.

Medi-Cal confusion

Sublingual Immunotherapy

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Hi Everyone,

I work for an allergist and we are starting to provide patients with sublingual immunotherapy (Grastek by Merck). The patient brings the tablet and takes the first dose in the office and is observed for 30 minutes after. There is no code in CPT for this administration. Any suggestions on how this should be billed? Thanks!

Sublingual Immunotherapy

Permacath Flush

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Permacath Flush

Apprentice Internship dilemma

Okay, so maybe not so much a dilemma, but very stressful situation for me. I am graduating in May with my Associates in Medical Administrative Assistance, I just took my CPC exam on the 13th and passed on my first try too . However, I am taking my internship in a few weeks and having panic attacks thinking of what they will give me because I want to do coding, but know realistically that I wont get a coding job (though I will still try). So, I was thinking of applying for a project Xternship in my area, and seeing what they give me at my school too.

My question with that is if I do the Xternship and the internship at my college, could both be counted as experience towards removing my A?

Any recommendations for job positions that would help me in working toward a coding career would also be greatly appreciated. I cant wait to get back into the workforce after three years of being a mom/student full time. I am beyond eager to start my career!

Apprentice Internship dilemma

Chronic Care Management

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Chronic Care Management

Looking for a link to Approved ASC procedures

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Looking for a link to Approved ASC procedures

Cms 2015 pfs

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Cms 2015 pfs

Exam results 12/13/2014 Toms River, NJ Ocean County College

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Exam results 12/13/2014 Toms River, NJ Ocean County College

Pqrs 2015

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Pqrs 2015

Allergy vials

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I am wondering if anyone has had issues getting payment on cpt code 95165? The reimbursement, when it gets reimbursed is very small and when we called on this we were told that the RVU's were lower than that of 95028. We also don't receive any reimbursement when we bill this code with anything else. We have been referred to a CCI edit but no one knows where to find this information. I am new to allergy so not sure if there is a work around on this issue. Any advice?

Allergy vials

Question RE: The "X" modifiers and surgery

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I have read so much on the new "X" modifiers but still can not find the answer to my question. Which "X" modifier would you use in a knee or shoulder scope (as an example) say...29827 and 29823,59. Which "X" modifier would you use in that scenario? Or, 29888 and 29881,59?

Thanks so much !!

Question RE: The "X" modifiers and surgery

Orthopedic Remote Surgical Coder

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Orthopedic Remote Surgical Coder

cochlear implant

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cochlear implant

Board certified to bill wcomp?

Hi Everyone,

This is a new one for me, as my old providers were all board certified in their fields. My boss is tell me one of our dr's can't see or bill workers comp patients insurance because he is not board certified. I can't finding anything on the subject however.

I'm in florida by the way.

Thanks,

Board certified to bill wcomp?

2% Sequestration Reduction

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2% Sequestration Reduction

Observation care

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Observation care

Unlisted code appropriateness

Hello,

I have questions and concerns in the numerous unlisted codes being reported on surgery claims coming through my department. The encounters are being coded by an outside company.

I've had almost 4 years of coding experience in just about every specialty and I have rarely used the unlisted codes. The amount unlisted codes being applied seem to be for things that are included in the surgical procedures listed. The procedures are not exactly new or out of the ordinary.

If there is any additional information that can be provided on reporting unlisted codes. Specifically in addition to other procedures being performed. My concern is that we may not be getting paid exactly what we should also possibly missing additional charges because frequent use of unlisted code.

Any feedback is much appreciated.

Unlisted code appropriateness

Billing Urgent Care for Total Health Care Insurance

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I know that every urgent care is different, however we were told to bill our urgent care claims for Total Health Care with all 99214s??? Has anyone ever heard of this, or been informed to do this? We have global codes for other insurance agencies (S9088, S9083 etc.), but it just seems incorrect that no matter what level of service that was performed, that THC requires you to bill a 99214. Goes against everything we ever learned about coding....any input???

Billing Urgent Care for Total Health Care Insurance

Reposting - anyone? need help with venography codes

Hi all,

I'm reposting this and hope someone can help. In looking at it again, I'm wondering if I should only use 36010/75827? Any input is appreciated.

Hi,

I'm not super familiar with venography coding. I thought 36010 for the placement in the SVC, and 36005/75820 for the venography. Would I use anything else for the "Selective injections performed in both the

left internal and external jugular veins"? Thank you!!

PROCEDURES PERFORMED: Left upper extremity and left central venogram, and

attempted recanalization of left subclavian vein occlusion.

IMAGING MODALITY UTILIZED: Ultrasound and fluoroscopy.

ACCESS SITE: Right common femoral vein, left axillary vein.

CATHETER POSITION: Left axillary vein and subclavian vein via left

axillary vein approach, left innominate vein via right transfemoral vein

approach, left internal jugular vein, left external jugular vein via a

right transfemoral venous approach.

TECHNIQUE:

The skin overlying the left upper extremity AV access site, left axilla,

and right groin were sterilely prepped and draped as above.

Initially under ultrasound guidance, after achieving local anesthesia with

1% lidocaine, the right common femoral vein was accessed. Over a guidewire

a 6 French sheath was inserted followed by placement of a 5 French

Berenstein catheter which was advanced across the right heart into the SVC.

Injection performed. Catheter further advanced into the left innominate

vein. Injection performed. Central left subclavian vein occlusion defined.

Multiple attempts were made at sharp recanalization of the left central

vein chronic occlusion in a retrograde fashion from a transfemoral approach

with a selection of various guidewires including stiff Glidewire. These

were unsuccessful. The catheter prolapsed into the prominent left external

and internal jugular veins. Selective injections were performed in both the

left internal and external jugular veins.

As such, a left transaxillary approach was elected. Under ultrasound

guidance, after achieving local anesthesia, the left axillary vein was

accessed in the high axilla. Over a guidewire a 5 French sheath was

inserted, followed by placement of 5 French Berenstein catheter. Catheter

positioned in the left axillary vein. Injection was performed. Catheter

further advanced into the left subclavian vein laterally, injections

performed. Prominent cervical collaterals were defined. The central left

subclavian occlusion defined. With the catheter wedged at the level of the

occlusion centrally, multiple attempts at recanalization using a variety of

guidewires including sharp dissection with a stiff Glidewire both proximal

and distal ends were performed. These were unsuccessful. The guidewire was

unable to penetrate the chronic cap. As such, the procedure was terminated.

The access sites were removed, and compression applied and hemostasis

achieved.

FINDINGS: Chronic occlusion of the left subclavian vein centrally at the

junction with the left innominate vein. There is prominent cervical

collaterals that descend through the right neck and suprascapular region,

and reconstitute the left external and internal jugular veins which

decompress into the left innominate vein. Unsuccessful attempts at

recanalization as described in detail above.

COMPLICATIONS: None.

IMPRESSION: RIGHT TRANSFEMORAL AND LEFT TRANSAXILLARY LEFT CENTRAL CHEST

VENOGRAPHY DOCUMENTS HIGH-GRADE CHRONIC FOCAL OCCLUSION OF THE LEFT CENTRAL

SUBCLAVIAN VEIN, REFRACTORY TO ATTEMPTS AT RECANALIZATION FROM BOTH TRANS-

FEMORAL RETROGRADE, AND TRANSAXILLARY ANTEGRADE APPROACHES.

Reposting - anyone? need help with venography codes

Looking for a Roommate at Nat'l Conference

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Looking for a Roommate at Nat'l Conference

epsitaxis

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A patient was in the ER with a nose bleed, a packing was placed 30905 and pt was discharged. The pt returned later in the day because of reoccuring epsitaxis and packing was removed and and a new one was replaced. It is correct to code the subsequent 30906 charge for the second packing even if it occured on a separte visit?

epsitaxis

2015 Books

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just seeing if everyone who ordered their books for 2015 received them all yet? getting kind of worried, i ordered physicians bundle 1 and received 2 books, cpt and icd9. last one said would arrive in December, but getting worried it was stolen or something

2015 Books

Question About Plastic Surgery

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Question About Plastic Surgery

Intraoperative bleeding

I need some confirmation on whether or not I chose the right code. For the following surgery I coded 37244. Can anyone tell me if this is correct.

REASON FOR CONSULTATION: Intraoperative bleeding.

INDICATION FOR PROCEDURE: A 43-year-old female who has been operated on for hysterectomy by the dr. Patient developed bleeding in the pelvis and was consulted for evaluation for hemostasis and control of bleeding.

INTRAOPERATIVE PROCEDURE: Upon entering the operating room, the area of bleeding was identified, appeared to be venous bleeding deep within the pelvis. The uterus had been removed and the stump was visualized. Upon prep evaluation of the operative site, on the patient's right deep within the

pelvis, there was venous bleeding. Sutures were placed to evaluate the bleeding stump. Several graspers were used and hemostatic suture with ligation of the right lateral wall of the vaginal cuff and the uterus stump. The remainder of the evaluation was for bleeding of the left stump. Evaluation of the pelvis posteriorly by retraction of the uterus down and the other structures towards the lateral side revealed bleeding on that side. This was controlled eventually by a figure-of-eight stitch of 0-Vicryl. This was done on the right side for adequate hemostasis and then on the patient's left side. At the end of the case, the pelvis was then reevaluated, hemostasis found to be adequate and the abdomen was then irrigated and closed. The Pfannenstiel incision midline was approximated by the Dr. and a

cephalad portion to prevent hernia at the umbilicus was placed. This was followed by closure of the fascia in the Pfannenstiel. After closure of the abdomen, the patient tolerated the procedure well. The dr. will dictate the previous hysterectomy part of the operation.

Intraoperative bleeding

Incision and debridement

I need help coding this surgery. I cannot decide if I should use 11043 or 13121 & 13122 with 97605. Please see notes below. Any help would be appreciated. Please tell me why you picked the codes you picked.

PROCEDURE PERFORMED: Incision and debridement of left forearm wound with sharp debridement of devitalized skin, muscle and fascia and placement of negative pressure wound dressing.

INDICATIONS: Patient is a 48-year-old male involved in a motor vehicle crash in which he was driving an 18-wheeler and rolled the truck with his window open, causing severe road rash and avulsion to his left forearm. Patient was initially tried with a nonoperative treatment of the wound with wound care. However on serial examinations, it became obvious that some of the tissue bridges that were present centrally within the wound had become devitalized or becoming necrotic and this was a nidus for infection therefore the patient was started on antibiotics and the decision was made to take him to the operating room.

DETAILED DESCRIPTION OF PROCEDURE: After obtaining consent, patient was rought to the operating theater, placed in supine position. Patient was intubated and put under general anesthesia with no incident. Time-out was

performed in which the patient was properly identified and all agreed on the procedure. Patient got preoperative Ancef 2 g IV. The left arm was placed on a board in a supinated position to expose the wound and was prepped using Betadine and draped in sterile fashion. The wound was examined again and found to have gross contamination still within pockets underneath some of the tissue bridges that were present. We began by doing sharp debridement of devitalized tissues at the borders of these tissue bridges, removing all dead tissue, several pieces of foreign debris such as glass and grass were encountered and removed after an initial round of removing this devitalized tissue, pulse lavage was performed using normal saline with chlorhexidine. At this time, it was determined that several of the tissue bridges would likely not survive and would service a nidus for further infection. In using cautery and sharp Mayos, these tissue bridges were debrided back to healthy bleeding tissue. A curette was then used to curettage the wall questionable tissue removing further necrotic tissue until the entire wound base was pink and viable tissue. Further exploration was done in all pockets with the curettage in order to ensure that all foreign objects had been removed. A single tissue bridge measuring 1.5 cm across on the proximal end of the wound was left as it is pink and bleeding and determined to be likely to survive. However it was curettaged well underneath it. Another round of pulse lavage was performed using 3 L of normal saline after this and the wound looked very clean.

Electrocautery was used to control all points of bleeding and good hemostasis was achieved. At this time, it was determined that we would place Silvadene gel over the wound. The wound was measured to be 16.5 cm x 9 cm. At this

time, it was determined that the wound would benefit from a negative pressure wound dressing and a _____, sponge was placed to sit over the wound and cut and placed in the normal fashion. After this was completed, it was attached to the KCI VAC system and a good seal had been obtained and was left at 125 mm of Hg continuous suction. At this time, the procedure was ended. The patient was woken from anesthesia and extubated without incident and remained stable throughout the entire case. the doctor was scrubbed and present for the entire case. Patient was then returned to the PACU in stable condition. Estimated blood loss was less than 10 mL. Specimens include anaerobic and aerobic wound cultures and left forearm wound tissue. There were no complications.

PLAN: The patient will be taken this Sunday for another look and possible further debridement and wound VAC change and will return to his room in the floor.

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Last edited by knperry; Today at 06:08 PM.



Incision and debridement

Self-Referrals

I am curious as to how many practices in this specialty take self-referrals outside of second opinions. It was my understanding that this was not allowed by Medicare and other big carriers. That was our practice rule as well when I began 10+ years ago.

Is this still the case or am I thinking too "old school"? If there are any links/written rules on this....please post here also!

Thanks in advance.

Self-Referrals

99214, 81001 pos 22

Dear Experienced Coders,

I have a question. IS E/m 99214 payable if coded with 81001 when place of service 22? Is urinalysis part of office visit? I know if place of service 11 we get reimbursed for 99214 and separately for 81001.

Awaiting your response,

Dahlia

99214, 81001 pos 22

Dexa scan documentation

I'm having trouble interpreting some findings on DEXA scans....

The physician states the indication for the test is a postmenopausal women under 65 with clinical indications for a bone density assessment

And the findings are:

Patient has osteopenia as determined by WHO criteria. In this patient the presents of compression fractures or osteoarthritic changes in the lumbar spine could spuriously increase the BMD of this region: precluding the use of this site as an indicator of osteostatus. Based on the results of the patients bone density assessment the risk of future fracture increases approximately two fold for each 1.0 SD decrease in T-score. Repeat two years unless clinically indicated.

So my confusion is in the findings...is that saying she has a compression fracture of the lumbar spine? or that she is just at risk of compression fracture because of the osteopenia?

Dexa scan documentation

Billing Flu Mist Admin w/well visit Medicaid

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Billing Flu Mist Admin w/well visit Medicaid

Physical Exam

I have a teaching physician scenario where the fellow documents the MDM only. The attending does document a compliant attestation and indicates he saw and examined the patient with the resident. The findings of the exam are not documented by the fellow or attending. I do see this portion in the MDM and am wondering if others would consider this a physical exam?:

No e/oGIB - stool in bag is light brown. NGT with minimal blood tinged output, <20cc in 24h.

Thank you so much for your help

Physical Exam

Lap hiatal hernia repair with falciform graft

The surgeon did a laparoscopic hiatal hernia repair, with a fundoplication. Instead of using a pre-packaged mesh, he took the falciform ligament off the abdominal wall and sutured it to the diaphragm repair (using it as a mesh).

Is it ok to use 43282 (lap hiatial hernia repair, with fundoplication, with mesh)?

Or, do I use 43281 (without mesh) and need to add another code? If so, which code is best? I have considered 49326 (laparoscopy with omentopexy), as the concept is similar, however omentum was not used. Or do I need to use an unlisted code, 49329?

Thanks for your help!

Lap hiatal hernia repair with falciform graft

Free Webinars and Free Practice Exams

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Free Webinars and Free Practice Exams

aapc exam

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aapc exam

OB/GYN Coding Guideline

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I need to the coding clinic for this case. I know there is a coding clinic for this particular case. I believe it is third quarter 2013. I don't have access to get this coding clinic guideline. Does anyone have this particular coding clinic guideline? Thank you.

An obstetric patient presents at full-term to undergo a repeat cesarean section. The patient was found to have a hysterotomy wound dehiscence, which has complicated the current admission.

OB/GYN Coding Guideline

Postop medical management

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The V45.89 is not a first listed code. You should use a follow up V67 code if there is nothing being done, or an aftercare code if there is still post op management such as suture removal or dressing changes or fitting and adjustments. Codes in categories, V54, V52, V53, V58 for example

__________________

Debra A. Mitchell, MSPH, CPC-H

Postop medical management

Latissimus flap deneravation with excion, thoracodorsal nerve

Please Help!!!

Procedure: A right latissiumus flap denervation with excision, thoracodorsal nerve: a right implant exchange: a right symmastria repair with Alloderm

Description of procedure: The patient was placed on the OR table in supine position. After induction of general anesthesia, the chest was prepped and draped in usual fashion. Initially, the lateral aspect of the mastectomy scar was excised beneath the right axilla. Exploration performed with identification of the lateral borders of the latissimus flap and the rotation point of the lattissimus flap in the axilla and then the thoracodorsal pedicle was identified in that area. A nerve stimulator was used and a 2-mA stiimulus confirmed the thoracodorsal nerve, which was then dissected over a 3-cm area, clipped and divided resecting the 3 cm length of the thoracodorsal nerve. That wound was then closed in layers with a combination of 3-0 PDS and 3-0 and 4-0 Monocryl. The medial aspect of the latissimus skin paddle scars was opened. Cautery dissection carried through the underlying subcutaneous tissue, muscle, and capsule. The implant was removed, which was a 500 mL Mento high-profile implant. The medial pocket evaluated and a capsulotomy performed on the anterior segment of the breast several centimeters from the area of excess pocket dissection, so a neosubpectoral pocket was dissected in that location and the capsule tacked back to the chest wall. With the laxity still o f the skin in that area, some additional suturing of that part of the pocket to the chest wall of the overlying flap was performed with an 0 Ethibond suture, and then within the area of the capsulotomy, a 6- x 16-cm AlloDerm was initially pie crusted and the sutured around 10- to 12-cm length of the medial pocket around 4 cm width. Interrupted 3-0 PDS was used for that tacking of the AlloDerm. A sizer was then placed with a 475 mL Allergan Style 410 FF sizer that was evaluated with the patient upright and then compared to a 425 mL Style 410 FF sizer with 410 overall having the best slope of the upper pole and a reasonable volume match, so that sizer was removed. The pocket irrigated with triple antibiotic solution. Gloves were changed. A 19-French JP drain was placed though an inferior stab incision up the medial gutter of the breast and then the 425 mL Style 410 FF implant was placed, followed by muscle and capsule closure with 3-0 Monocryl and then layered skin closure with 3-0 and 4-0 Monocryl. Dermabond and ABD dressings were applied along with a breast binder garment. Blood loss 25 mL. The patient was taken to recovery room stable.

I have the implant exchange and alloderm codes, I just don't know the code for the denervation.

Thanks in advance.

Latissimus flap deneravation with excion, thoracodorsal nerve

coding position in Roanoke, VA

This is not a remote position:

Very busy multispecialty Medical Billing Office is seeking a Certified Medical Coder. Experience is preferred but not necessary. Hours Monday through Friday 8:00-4:30 (some overtime may be required), vacation and holiday package. Salary commensurate with experience.

Please send me a message with your resume and AAPC ID# if you are interested. Or you may email your resume with AAPC ID# to kelly@egglestonandeggleston.com

coding position in Roanoke, VA

Open shoulder deltoid repair

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Open shoulder deltoid repair

Cervical Length

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Cervical Length

Labs/pathologies

Need help! Looking for advice/guidance on labs/path for facility reporting. I am completely new to these, and I am not sure modifier 59 is appropriate on some of these. I have been researching online etc to no avail. For example:

G0461 and G0462 with 88360..when is ok to use the mod? If anyone has anything they can steer me towards to find this information, that would be so amazing!!

Thanks!

Labs/pathologies

Non Face to Face Visit

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I need a little help with a provider that visiting with family of a patient but the patient was not there to discuss placing the patient in a nursing new. Are there any billable and payable E/M Code or codes I could use for this type of visit.

Thanks,

__________________

Jennifer Pfister, CPC

Non Face to Face Visit

Need help with Clarix amniotic membrane graft

I am having a hard time finding a code for the placement of a Clarix amniotic membrane graft. I have two encounters:

1st - Clarix amniotic membrane graft inserted intraarticularly and subcuticulary and first MTP for reduction of inflammation, joint surface tissue formation.

2nd - Clarix amniotic membrane graft right and left third intermetatarsal space.

I don't see how this would be the 15275 area as it is not a skin graft (topical placement).

Any suggestions?

Need help with Clarix amniotic membrane graft

Therapeutic volatile anesthesia

Dear colleagues,

Please help me to code anesthesia for the case below (general anesthesia was administered for the period of 7 hours):

9yoM previously healthy, in status epilepticus for one month, after 4 day prodromic illness of fever, diarrhea and headache. Scheduled for trial of therapeutic volatile anesthesia to produce burst suppression and break status epilepticus after failure of all other medical interventions.

Thank you.

Therapeutic volatile anesthesia

peripheral angiogram and stent order of coding and modifiers

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I am coding a bilateral lower extremity angiography with distal vessel runoff, and stent placement in the mid left superficial femoral artery and mid left common iliac artery segments. The doctor thinks the following codes should be reported but I am not sure if some are inclusive of others and I don't know what order they should be listed and which ones require modifiers. Should I be using modifier 59 anywhere?

37221

37227

36247

75716-26

peripheral angiogram and stent order of coding and modifiers

CPC-A ISO PT/FT in Lehigh Valley PA, Poconos, or NJ

Hello, Happy Holidays! I recently obtained my CPC-A, and am enrolled in college, graduating in May with an AAS in Medical Administrative Assistance, and currently have a specialized diploma in Medical Billing. I have a 3.56 GPA, and am a member of Phi Theta Kappa.

I have worked briefly in a hospital as a Unit Clerk, and over 10 years experience in Customer Service. I have a resume available upon request.

CPC-A ISO PT/FT in Lehigh Valley PA, Poconos, or NJ

Robotic colectomy additional code ?

During a robotic colectomy the surgeon does an evaluation of the blood supply to the bowel flaps with "firefly" and asked if he can bill an additional code for the evaluation.

He suggested 15860 angiographic evaluation of colonic flap performed with immunofluorescence.

Has anyone billed this along with a colectomy?

Any suggestions would be greatly appreciated!

Robotic colectomy additional code ?

I need ICD 9 Coding help with Malnutrition and BMI

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I need ICD 9 Coding help with Malnutrition and BMI

Billing 95937 for TO4

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Billing 95937 for TO4

HELP, placement of biologic mesh

patient had undergone incisional hernia repair and mesh became infected and was subsequently removed. Two days later patient taken back for washout and replacing mesh. Need help coding this note:

PREOPERATIVE DIAGNOSIS: Infected ventral hernia mesh.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE: Abdominal wound washout, placement of Strattice biologic mesh (20 x 30 cm mesh trimmed at 19 X 27 cm), and wound VAC placement.

ANESTHESIA: General.

SPECIMENS: None.

FINDINGS: The posterior sheath remained intact. The posterior rectus space appears healthy. No purulence and no fluid collections. All the tissue appears viable and healthy.

ESTIMATED BLOOD LOSS: Less than 100 mL.

IMPLANTS: Strattice mesh (20 x 30 cm mesh trimmed to 19 x 27 cm).

INDICATIONS FOR THE PROCEDURE: The patient is a 71-year-old female who had undergone a Stoppa incisional hernia repair. The posterior rectus sheath had developed a defect and the mesh was exposed to the small bowel. This resulted in a small bowel obstruction and then subsequent erosion and perforation of the small bowel into the retrorectus space. The infection was confined to this location. She had undergone lysis of adhesions with small bowel resection and then abdominal washout. The posterior rectus sheath at the left lateral aspect where the defect was prepared primarily. The wound was copiously irrigated at that time and a wound VAC was placed in the posterior rectus space. She had undergone IV antibiotic therapy. Plan is made for return to the OR for wound evaluation and if appropriate placement of biologic mesh. The risks and benefits, and alternatives of procedure were discussed with the patient and her family and they wished to proceed.

DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room theater. She was placed in supine position. General anesthesia was induced. She was receiving systemic antibiotic therapy. The patient's wound VAC was taken down and the abdomen was prepped in the normal sterile fashion and draped. The sponge from the wound VAC was removed. The lower sponge and the posterior rectus sheath was also carefully removed. The posterior rectus sheath was found to be intact. The posterior rectus space was all found to be healthy in appearance. There was no purulent fluid. There are no fluid collections. This all had a healthy wound base. 1000 mL of irrigation was then irrigated to the space with a Pulsavac irrigator. The defect was then measured. This measured 19 cm in the craniocaudal direction by 27 cm transversely. A 20 x 30 cm Strattice biologic mesh was then chosen. This was then trimmed to this size. This was then placed in a retrorectus position from her prior component separation. This was then tagged at the lateral aspect with 0 Vicryl sutures. Using a suture passer device, these were then passed transcutaneously. This was done circumferentially around the margins of the mesh. This then laid in excellent fashion. These were then tied down. A 15 round drains were then placed to each lateral recess site. These were secured with 3-0 nylon. The anterior rectus sheath was then closed over the mesh, taking intermittent small bites of the mesh to fix this in the midline. This was done with a PDS plus antibiotic suture and tied in the middle. Prior to closing this, hemostasis was evaluated and was found to be excellent. A wound VAC was then placed to the subcutaneous tissues. This held an excellent seal.

The patient tolerated the procedure well. There were no complications. All counts were correct as reported to me at the end of the case.

HELP, placement of biologic mesh

Rotator Cuff Repair- not repairable

This is a 2 part question.

First my surgeon was attempting to fix the patient's rotator cuff tear. He began arthroscopic and it was not going well so he changed to open.

The tear was pretty bad... "the stitch pulled out of the tissue as he had very poor quality rotator cuff tissue. At this point, it was determined that his rotator cuff was not repairable so I copiously irrigated the subacromial space."

The first question is would I cpt 23410 and append a 53 modifier (for discontinued procedure).

2nd question is this. The surgery was started as arthroscopic. He did a subacromial decompression and acromioplasty arthroscopically. And then he attempted to correct the rotator cuff arthroscopically. That was when he changed to open, due to the complexity of the rotator cuff injury.

29826 [subacromial decompression and acromioplasty] is an add-on code. I cannot bill this if there is no other procedure. Since the doctor converted to open, am I able to bill subacromial decompression and acromioplasty as open [23130] ??

Rotator Cuff Repair- not repairable

[unable to retrieve full-text content]

Hematoma

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Hematoma

UA to rule out infection

We have a patient who comes in for his foley cath changes. A week before getting the change, the doctor will sometimes have him do a UA to rule out an infection before the cath is changed. Patient has no symptoms of a UTI or anything. What diagnosis would I use for the UA? He has a cath for retention and I'm not sure if that's the dx I should use.

Thanks

Tori

UA to rule out infection