+ Janet McCauley, MD, MHA, CPC, FACOG April 6, 2019 + Background - - PowerPoint PPT Presentation

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Janet McCauley, MD, MHA, CPC, FACOG April 6, 2019

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Background Evaluation and Management “E&M”

 Problem oriented  Consultations  Preventive services

Coding examples

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Surgical Coding Modifiers Obstetrical Global Ultrasound Coding Examples

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Thank you Dr. Craig Sobolewski for contribution of Surgical Coding Scenario

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CPT Global Package

 Includes:  Preoperative—Services beginning one day prior  Intra-operative—All usual intra-operative

procedures

 Postoperative--Related visits for:

 0 or 10 days (minor procedure)  90 days (major procedure)  May use CPT 99024 for EM visits during post op

period for reasons related to original procedure

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Does not include: Intra-operative—Unrelated procedures Post-operative

 Visits unrelated to the diagnosis for surgery  Services for added course of treatment  Care from physicians/QHPs outside surgical group or

another specialty within multispecialty group

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Modifiers

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 -22 Unusual services

 -51 Multiple procedures

Exceptions:

 Add-on codes  Separate procedure designation by CPT  -59 Distinct procedural service  -58 Staged or related procedure in post op period  -79 Unrelated procedure by same surgeon during post op period  Appended to procedure code

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 -24 Unrelated E/M service in post op period  -25 Significant, separately identifiable E/M by same

physician or other qualified health professional, on same day as procedure

 -57 Decision for surgery  Appended to EM code

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Modifier Description 80 Assistant Surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon (when qualified resident not available) 62 Two Surgeons (co-surgery) 66 Surgical Team AS PA, NP, or CNS services for assistant-at-surgery (Medicare)

From ACOG Coding Workshop Gynecological Surgical Coding 2017

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 Surgeons working together to perform distinct parts of a

single procedure

 Each surgeon has key role in the performance of the

procedure

 Both surgeons report same CPT code and modifier  Co-surgeon may also serve as assistant on additional

procedures

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 58200 TAH, partial vaginectomy, para-aortic and pelvic

lymph node sampling with/without removal of tubes/ovaries

 General Gynecologist: Hysterectomy  Gynecologist/Oncologist: Lymph nodes  Each reports same code, same modifier and own

established fee

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 Ms. Potter is a 22-yo who presents to the ER on 12/24

with c/o vaginal bleeding, abdominal pain, and fever. LMP is 3 weeks late. Dr. Benjamin B, the ER physician

• rders a stat hCG and U/S and consults Dr. Peter R, the
• n-call GYN. Pelvic exam reveals normal uterus and right

adnexal tenderness. Stat hCG is 4000 mIU/mL. U/S in the radiology department reveals an empty uterus and a 2.5 cm mass near the right ovary. Dr. Peter R diagnoses an ectopic pregnancy and takes Ms. Potter to the OR that day for laparoscopic treatment.

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 Intraoperatively, severe pelvic adhesions are

• encountered. VS remain stable. Dr. Cottontail, a general

surgeon, is called to assist with adhesiolysis. 60 minutes

• f adhesiolysis is required in order to identify the right
• adnexa. A right salpingectomy is performed by Dr. Peter
• R. The appendix appears swollen and injected. Dr.

Cottontail performs an appendectomy. Ms. Potter does well and is d/c’ed home the following day.

 One week later. Ms. Potter is seen by Dr. Peter R for a

c/o of right breast tenderness

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 On 12/24:  Dr. Peter R  9924X-57 Outpatient consultation, decision for surgery same day  59151-22 Laparoscopic tx of ectopic w/ salpingectomy and/or

• ophorectomy

 44970-80(2nd)  Dr. Cottontail  44970-22 Laparoscopic

appendectomy

 59151-80(2nd)  One week later:  Dr. Peter R  9921X-24 Established

• ffice/outpt visit, unrelated to

surgery

• Drs. Peter R and Cottontail

+On 12/24:

 9924X-57  O00.90 Unspecified ectopic w/out IUP  Z3A.01 Less than 8 weeks gestation of pregnancy  59151-22  O00.101 R Tubal pregnancy w/out IUP  Z3A.01  N73.6 Pelvic adhesions,

female

 44970-22  K35.80 Unspecified

acute appendicitis

 N73.6 Pelvic adhesions,

female One week later:

 9921X-24  N64.4 Mastodynia

• Drs. Peter R and Cottontail

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59400 Routine care, antepartum, vaginal

delivery, postpartum care

59510 Routine care, antepartum, cesarean

delivery, postpartum care

59610 Routine care, antepartum, vaginal

delivery, postpartum care, after prior CS

59618 Routine care, antepartum, cesarean

delivery, postpartum care, attempted vaginal after prior CS

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 Up to 13 pregnancy related

• utpatient visits

 Visit where OB record

initiated

 Routine screening  Some payers may include

allowance for diagnostic testing (ex. ultrasound, NST)—payer specific

 Diagnosis of pregnancy  Medical or surgical conditions

unrelated to pregnancy

 Z33.1 “pregnancy state,

incidental” as secondary diagnosis may or may not bundle

 Inpatient and outpatient

hospitalization

 Ultrasound and monitoring

Included: Excluded:

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 Admission H&P within 24

hours of delivery

 Uncomplicated labor  Induction  Cervical dilator placed

same day

 Simple cerclage removal  Delivery of infant and

placenta

 Hospital observation or

admission, and subsequent visits, more than 24 hours before delivery

 External cephalic version  Cervical dilators placed day

before delivery

 Delivery of Twin B  May be payer specific

Included: Excluded:

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 Post delivery inpatient

care

 Vag Del: 2 days  CS: 4 days

 Postpartum outpatient

visit

 Vag Del: 1-2 visits within 6

weeks

 CS: 2 visits

 Visits to treat

complications or disease unrelated to routine pp care

 Delayed hemorrhage  Wound infection  Other med/surg conditions

 Inpatient conditions

requiring care > 2 (Vag Del) or 4 (CS) days

Included: Excluded:

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Report after delivery: additional E/M services if >13

antepartum visits (may be payer specific)

Report at time of service Additional diagnostic testing or procedure Hospital admission or observation when discharged

undelivered (unless returns for delivery <24 hrs)

Don’t report additional visits related to previous

history unless problem develops

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Use for transfers of care and pregnancy loss Do NOT use for coverage Options:

 Less than 4 antepartum visits: Use E/M code  4-6 antepartum visits: 59425  7+ antepartum visits: 59426  Delivery only: 59409, 59514, 59612, 59620  Does not include inpatient pp care  Delivery and pp care: 59410, 59515, 59614, 59622  Placenta only: 59414  Postpartum only: 59430

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 All OB codes found in Chapter 15 in ICD-10-CM

 (Codes O00-O9A)

 Many require 7th character to identify fetus with complication  Codes from O09 for supervision of high risk pregnancy: list first

for outpatient visits

 Codes O00-O9A require additional Z3A.** codes to identify

gestational age

 Codes in ICD-10-CM distinguish:  Conditions prior to pregnancy vs. conditions as result of

pregnancy

 High-risk pregnancies vs. complications during delivery

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 Chapter 21: Factors Influencing Health Status and

Contact with Health Services (Z00-Z99)

 Status codes  History (of)  Screening  Observation  Counseling  Encounters for obstetrical and reproductive services, including

weeks of gestation and supervision of normal pregnancy

 Used for many types of services, not just OB:

 Such as: Routine care, reason for screening test, risk factors,

follow-up

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 Diagnostic and procedure code combinations tell:  Why (missed ab vs. complete vs. incomplete vs.

induced vs. ectopic)

 When (termination vs. delivery code)  How (surgical vs. medical)  Which procedure (D&C, D&E, injection,

suppository)

 Be aware of benefit coverage limits for elective and

therapeutic terminations

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 Supervision of test  Interpretation  Written report  Use -26 when interpreting

study where facility or other entity owns equipment and pays tech

 Do not use if radiologist

provides report

 Technician salary/benefits  Equipment  Supplies  Facility uses –TC when you

interpret study instead of radiologist

 If you own machine and

employ technician, do not report either modifier

Professional Component (26) Technical Component (TC)

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CPT 76801-76817 Specific components required (+) codes for each additional gestation Code relevant and most specific diagnosis O09 series “Supervision of high risk pregnancy” as

• nly diagnosis may or may not be recognized

Z03.7(+5th digit) series “Encounter for suspected

maternal and fetal conditions ruled out” may be needed for some referrals

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76830 (TV), 76856 (Abd), 76857 (Abd

limited)

76831/58340 (SIS), 74740/58340 (HSG) Needs separate record and permanent image Don’t report when used to complete physical

exam

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 Multiple ultrasound

 76801+76817, 76801+76813, 76856+76830  Each code represents unique service  Document needs and results for each  Payer may bundle or require modifier (-59, -51)

 E/M with ultrasound

 Treat like other procedures w/ E/M  Needs documentation of distinct and separate service (-25 to

E/M code)

 Avoid unbundling

 Example: 76818 (complete BPP) includes 59025 (NST)  Don’t report 76819 (BPP w/out NST) + 59025

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Bessie B. returns to the office for her

scheduled ultrasound. The ultrasound shows normal endometrium and ovaries, with no apparent anatomic findings to account for her irregular bleeding. You spend 18 minutes counseling Bessie about results and interpretation of the ultrasound.

Select the appropriate E&M and/or

procedural codes

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ICD-10-CM for ultrasound same as office

visit:

 N92.1 Menometrorrhagia  Z68.31 BMI between 31.0-31.9, adult  Chronic anovulation/infertility not confirmed at this

visit, so not reported

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76830 Transvaginal ultrasound ?99213

 No E/M recommended for this scenario  Report procedure code alone if:

 Decision to perform procedure made previously  E/M service did not require extensive hx, PE, medical decision

making, or time

 Discussion focuses on results and interpretation of scan

 If “separately identifiable” service:

 Amend E/M code with modifier -25  Document distinct visit in the medical record

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Bessie reports to the clinic noting menses 1

week late. You perform an expanded problem-focused history and physical

• examination. Office pregnancy test is
• positive. You discuss the results of the

pregnancy test, give her a prescription for prenatal vitamins, and schedule her first prenatal visit in one month.

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At 6 weeks gestation, she is seen as a work-

in because of a complaint of vomiting for the last 3 days.

At 8 weeks, she is seen for her first prenatal

visit, and the OB record is initiated. Declines first trimester screening.

At 12 weeks, she is seen for her routine

prenatal visit. Fetal heart tones are heard.

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At her 16 week visit, she notes urinary

urgency and frequency, and is diagnosed with a urinary tract infection.

At 18 weeks, she returns for a routine

morphology ultrasound. You do not see her in the office, but review the scan and phone her later that afternoon to inform her no abnormalities were found.

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Bessie is then seen at 20 weeks, then every 4

weeks until 28 weeks gestation.

At 29 weeks, she returns with nausea and

• vomiting. Family members have had similar
• symptoms. You diagnose a viral gastro-

enteritis and prescribe conservative treatment.

She returns 1 week later at 30 weeks, and

feels much better. You see her biweekly until 34 weeks.

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At 34 weeks, she develops mild hypertension

and is seen weekly through 39 weeks

Two days after her 39 week visit, she

delivers vaginally a healthy 8 lb female

• infant. Blood pressure is normal after
• delivery. Postpartum course is uneventful,

and she is seen for a routine 2 and 6 week postpartum visits.

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20 Total visits 15 Included in global (CPT 59400):

 13 antenatal (8, 12, 16, 20, 24, 28, 30, 32, 34,

36, 37, 38, 39 weeks)

 plus postpartum*2

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20 Total visits

 15 Included in global

5 Excluded from global

 4 E&M

 Diagnosis of pregnancy at 6 weeks (9921x, billed at

time of service)

 Pregnancy related at 6 and 35 weeks (billed w/

global), in excess of 13 visits

 Pregnancy unrelated at 29 weeks (billed at time of

service)

 1 Procedure (Ultrasound at 18 weeks)

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Diagnosis codes

 N92.5 Other specified irregular menstruation  Z32.01 Encounter for pregnancy test, positive result

Procedure codes

 9921x Established outpatient visit  81025 Urine pregnancy test

Not included in global Billed at time of service

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 At 6 weeks gestation:  O21.0 Mild hyperemesis gravidarum  Z3A.01 Less than 8 weeks gestation  9921x Established outpatient visit  Bill at time of global since related to pregnancy, excess of 13

visits

 At 8 and 12 weeks:  Z34.01 Supervision of normal first pregnancy, first trimester  Per ICD-10-CM definitions:

 First trimester, less than 14 weeks 0 days  Second trimester, 14 weeks 0 days through less than 28 weeks 0 days  Third trimester, 28 weeks 0 days until delivery

 Included in global

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 At 16 weeks:  Z34.02 Supervision of normal first pregnancy, second

trimester

 R35.0 urinary frequency, R39.15 urinary urgency  Scheduled OB visit, part of global  At 18 weeks:  Z34.02 Supervision of normal first pregnancy, second

trimester

 76805 Ultrasound, pregnant uterus, >=14wk 0 day  Report at time of service unless payer contract specifies

• therwise

 No office visit (E/M or global) as no face-to-face time

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 Visits every 4 weeks until 28 weeks:  Z34.02/Z34.03 Supervision of normal first pregnancy,

second/third trimester

 3 visits attributed to global (20, 24, 28 weeks)  At 29 weeks:  A08.39 Viral gastroenteritis, acute infectious  Z33.1 Pregnant state, incidental  9921x Established outpatient visit  Bill at time of visit since unrelated to pregnancy  Biweekly 30-32 weeks  Z34.03 Supervision of normal first pregnancy, third trimester  2 visits attributed to global (30, 32 weeks)

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 At 34 weeks:  O16.3 Unspecified maternal hypertension, third trimester  Z3A.34 =34 weeks gestation  Scheduled OB visit, part of global  At 35 weeks:  O16.3 Unspecified maternal hypertension, third trimester  Z3A.35 =35 weeks gestation  9921x Established outpatient visit  Bill at time of global since related to pregnancy, excess of 13 visits  At 36-39 weeks:  O16.3 Unspecified maternal hypertension, third trimester  Z3A.36/Z3A.37/Z3A.38/Z3A.39 =36-39 weeks gestation  Scheduled OB visits, part of global (4 visits)

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 O16.3 Unspecified maternal hypertension, third

trimester

 Z3A.39 =39 weeks gestation  Z37.0 Single liveborn  59400 Global maternity care, including antepartum

care, vaginal delivery, and postpartum care

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