Coding Companion for Cardiology/Cardiothoracic/ Vascular Surgery a Comprehensive Illustrated Guide to Coding and Reimbursement

ATCR.book Page 1 M onday, N ovem ber 21, 2011 2:11 PM

Coding Companion for Cardiology/Cardiothoracic/ Vascular Surgery A comprehensive illustrated guide to coding and reimbursement

2013 ATCR.book Page i M onday, N ovem ber 21, 2011 2:11 PM

Contents

Getting Started with Coding Companion ...... i Diaphragm ...... 574 Breast ...... 1 Esophagus ...... 577 General Musculoskeletal ...... 2 Abdomen ...... 624 Neck and Thorax ...... 4 Thyroid Gland ...... 629 Larynx ...... 24 Parathyroid...... 630 Trachea and Bronchi ...... 28 Nervous System...... 633 Lungs and Pleura ...... 58 Medicine ...... 640 Heart and Pericardium ...... 132 Appendix...... 702 Arteries and Veins ...... 288 Evaluation and Management ...... 757 Lymph Nodes ...... 567 Index...... 777 Mediastinum ...... 570

CPT only © 2011 American Medical Association. All Rights Reserved. © 2011 Optum Coding Companion for Cardiology/Cardiothoracic/Vascular Surgery Contents (Potts-Smith type operation), for flow to one stenosis. Narrowing or constriction of a 33750 lung (classical Glenn procedure), see 33766. passage. For superior vena cava to pulmonary artery 33750 Shunt; subclavian to pulmonary artery tetralogy of Fallot. Specific combination (Blalock-Taussig type operation) for flow to both lungs (bidirectional Glenn procedure), see 33767. of congenital cardiac defects: obstruction of the right ventricular outflow tract with ICD-9-CM Procedural pulmonary stenosis, interventricular septal defect, malposition of the aorta, overriding 39.0 Systemic to pulmonary artery shunt the interventricular septum and receiving 39.61 Extracorporeal circulation auxiliary to blood from both the venous and arterial open heart surgery systems, and enlargement of the right ventricle. Anesthesia tricuspid atresia. Congenital absence of 33750 00560 the valve that may occur with other defects, such as atrial septal defect, pulmonary atresia, ICD-9-CM Diagnostic and transposition of great vessels. 424.3 Pulmonary valve disorders Waterston procedure. Type of 745.2 Tetralogy of Fallot aortopulmonary shunting done to increase 746.01 Congenital atresia of pulmonary valve pulmonary blood flow where the ascending 746.02 Congenital stenosis of pulmonary aorta is anastomosed to the right pulmonary valve artery. 746.09 Other congenital anomalies of pulmonary valve CCI Version 17.3 0213T, 0216T, 0228T, 0230T, 32100, 32422, 746.1 Congenital tricuspid atresia and 32551, 33140-33141, 33210-33211, stenosis 33254-33256, 33310-33315, 36000, 746.2 Ebstein's anomaly 36400-36410, 36420-36430, 36440, 36600,

746.9 Unspecified congenital anomaly of 36640, 37202, 39000-39010, 43752, Heart Explanation heart 51701-51703, 62310-62319, 64400-64435, In its unmodified form, this operation involves 64445-64450, 64479, 64483, 64490, 64493, dividing the left subclavian artery, tying off Terms To Know 64505-64530, 69990, 93000-93010, and the end of the artery going to the arm, and 93040-93042, 93318, 94002, 94200, 94250, atresia. Congenital closure or absence of a 94680-94690, 94770, 95812-95816, 95819, creating a connection between the end of this Pericardium artery coming from the heart and the side of tubular organ or an opening to the body 95822, 95829, 95955, 96360, 96365, 96372, the pulmonary artery. The difficulty with this surface. 96374-96376, 99148-99149, 99150 Note: These CCI edits are used for Medicare. operation is making the connection to the Blalock-Taussig procedure. Anastomosis pulmonary artery exactly the right size to Other payers may reimburse on codes listed of the left subclavian artery to the left supply adequate, but not excessive blood flow above. pulmonary artery or the right subclavian artery to the lungs. Instead, a modified version of to the right pulmonary artery in order to shunt the operation is usually performed. The artery Medicare Edits some of the blood flow from the systemic to to the arm is not divided. Instead, one end of the pulmonary circulation. Fac Non-Fac a 3 mm to 5 mm diameter tube of Gortex is RVU RVU FUD Status sewn to the side of the artery to the arm and cardiopulmonary bypass. Venous blood 33750 41.7 41.7 90 A the other end is sewn to the side of the is diverted to a heart-lung machine, which pulmonary artery. The size of the tube mechanically pumps and oxygenates the MUE Modifiers 33750 1 51 N/A 62* 80 determines the amount of blood flow to the blood temporarily so the heart can be * with documentation lungs. Cardiopulmonary bypass is not bypassed while an open procedure on the required. The ductus arteriosus (a connection heart or coronary arteries is performed. During Medicare References: None between the aorta and pulmonary artery that bypass, the lungs are deflated and immobile. has been supplying blood to the lungs, but usually closes at birth) is tied off. congenital. Present at birth, occurring through heredity or an influence during Coding Tips gestation up to the moment of birth. This procedure is sometimes performed in Potts-Smith-Gibson procedure. conjunction with 33684. When ligation and Side-to-side anastomosis of the aorta and left takedown of systemic-to-pulmonary artery pulmonary artery creating a shunt that shunt is performed in conjunction with this enlarges as the child grows. procedure, it should be reported separately; see 33924. Do not append modifier 63 to shunt. Surgically created passage between 33750 as the description or nature of the blood vessels or other natural passages, such procedure includes infants up to 4 kg. For as an arteriovenous anastomosis, to divert or shunt, ascending aorta to pulmonary artery bypass blood flow from the normal channel. (Waterston type operation), see 33755. For descending aorta to pulmonary artery

CPT only © 2011 American Medical Association. All Rights Reserved. © 2011 Optum Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery Heart and Pericardium — 239 maintain blood pressure. Report 36455 if the child 36400 36415-36416 is other than a newborn. 36400 Venipuncture, younger than age 3 years, 36415 Collection of venous blood by necessitating physician's skill, not to be venipuncture 36510 used for routine venipuncture; femoral or 36416 Collection of capillary blood specimen (eg, 36510 Catheterization of umbilical vein for jugular vein finger, heel, ear stick) diagnosis or therapy, newborn Explanation Explanation Explanation A needle is inserted through the skin to puncture A needle is inserted into the skin over a vein to The physician catheterizes the umbilical vein for the femoral or jugular vein of a child younger than puncture the blood vessel and withdraw blood for diagnostic or therapeutic purposes. The physician age 3. The needle is inserted into the vein and used venous collection in 36415. In 36416, a prick is cleanses the umbilical cord stump and locates the for the withdrawal of blood for diagnostic study or made into the finger, heel, or ear and capillary blood umbilical vein. A catheter is inserted in the vein for for the therapeutic infusion of intravenous that pools at the puncture site is collected in a reasons including blood sampling or administering medication. A soft flexible catheter may be placed pipette. In either case, the blood is used for medication. for prolonged therapy. Once the procedure is diagnostic study and no catheter is placed. complete, the needle or catheter is withdrawn and pressure is applied over the puncture site to control 36660 bleeding. Use this code for venipuncture 36420-36425 36660 Catheterization, umbilical artery, newborn, necessitating a physician's skill, not when routine 36420 Venipuncture, cutdown; younger than age for diagnosis or therapy venipuncture is performed. 1 year 36425 age 1 or over Explanation The physician catheterizes an umbilical artery in a 36405-36406 newborn for diagnostic or therapeutic purposes. 36405 Explanation Venipuncture, younger than age 3 years, The physician prepares the umbilical artery and necessitating physician's skill, not to be The physician makes an incision in the skin directly passes a catheter sheath inside the lumen for arterial used for routine venipuncture; scalp vein over the vessel and dissects the area surrounding access. The catheter is attached to a pressure line 36406 other vein the vein. A needle is passed into the vein for the that maintains patency of the arterial lumen. The withdrawal of blood or for the infusion of access is used for diagnostic or therapeutic purposes, Explanation intravenous medication of a patient under 12 allowing the drawing of blood for tests or instillation A needle is inserted through the skin to puncture a months of age (in 36420) or over 12 months of age of medication. vein of a child younger than age 3. In 36405, the (in 36425). A catheter may be left behind. Once scalp vein is punctured and in 36406, a vein other the procedure is complete, the incision is repaired 70373 than the femoral, jugular, or scalp vein is used. The with a layered closure. 70373 Laryngography, contrast, radiological needle is inserted into the vein and used for the withdrawal of blood or for the therapeutic infusion 36430 supervision and interpretation of intravenous medication. A soft flexible catheter 36430 Transfusion, blood or blood components may be placed for prolonged therapy. Once the Explanation procedure is complete, the needle or catheter is Explanation A radiographic contrast study is performed of the withdrawn and pressure is applied over the puncture larynx, or organ of voice. Iodized oil is given in The physician transfuses blood or blood components site to control bleeding. Use this code for conjunction with the examination via tubing, which to a patient. The physician establishes venous access venipuncture necessitating a physician's skill, not allows oil to drip down the patient's throat at the with a needle and catheter and transfuses the blood when routine venipuncture is performed. radiologists discretion. The radiologist, via x-ray products. fluoroscopy, simultaneously watches the image 36410 amplified and displayed on a TV monitor. Rapid film 36410 Venipuncture, age 3 years or older, 36440 sequencing must be used to record the image, 36440 Push transfusion, blood, 2 years or younger which may then be studied and interpreted by the necessitating physician's skill (separate radiologist. procedure), for diagnostic or therapeutic Explanation purposes (not to be used for routine The physician performs a push transfusion on a child venipuncture) 70496-70498 2 years old and under. The physician calculates the 70496 Computed tomographic angiography, amount of blood to be transfused and slowly injects head, with contrast material(s), including Explanation it into the patient using a needle or existing noncontrast images, if performed, and A needle is inserted through the skin to puncture a catheter. vein of a person 3 years of age or older. The needle image postprocessing is inserted into the vein and used for the withdrawal 36450-36455 70498 Computed tomographic angiography, Appendix of blood for diagnostic study or for the therapeutic neck, with contrast material(s), including 36450 infusion of intravenous medication. A soft flexible Exchange transfusion, blood; newborn noncontrast images, if performed, and 36455 catheter may be placed for prolonged therapy. Once other than newborn image postprocessing the procedure is complete, the needle or catheter is withdrawn and pressure is applied over the Explanation Explanation puncture site to control bleeding. Use this code for The physician performs an exchange transfusion on Computed tomographic angiography (CTA) is a venipuncture necessitating a physician's skill, not a newborn. The physician calculates the blood procedure used for the imaging of vessels to detect when routine venipuncture is performed. volume to be transfused. A needle is placed in an aneurysms, blood clots, and other vascular artery or in an existing arterial catheter. The patient's irregularities. Contrast medium is rapidly infused blood is removed and replaced simultaneously to intravenously, at intervals, usually with an automatic

© 2011 Optum CPT only © 2011 American Medical Association. All Rights Reserved. 702 — Appendix Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery ATCR.book Page 757 M onday, November 21, 2011 2:11 PM

Evaluation and Management Evaluation and Management

This section provides an overview of evaluation and management The specifics of the code components that determine code selection (E/M) services, tables that identify the documentation elements are listed in the table and discussed in the next section. Before a associated with each code, and the federal documentation level of service is decided upon, the correct type of service is guidelines with emphasis on the 1997 exam guidelines. This set of identified. guidelines represent the most complete discussion of the elements of the currently accepted versions. The 1997 version identifies both Office or other outpatient services are E/M services provided in the general multi-system physical examinations and single-system physician’s office, the outpatient area, or other ambulatory facility. examinations, but providers may also use the original 1995 version Until the patient is admitted to a health care facility, he/she is of the E/M guidelines; both are currently supported by the Centers considered to be an outpatient. for Medicare and Medicaid Services (CMS) for audit purposes. A new patient is a patient who has not received any face-to-face Although some of the most commonly used codes by physicians of professional services from the physician within the past three years. all specialties, the E/M service codes are among the least An established patient is a patient who has received face-to-face understood. These codes, introduced in the 1992 CPT® manual, professional services from the physician within the past three years. were designed to increase accuracy and consistency of use in the In the case of group practices, if a physician of the exact same reporting of levels of non-procedural encounters. This was specialty or subspecialty has seen the patient within three years, the accomplished by defining the E/M codes based on the degree that patient is considered established. certain common elements are addressed or performed and reflected in the medical documentation. If a physician is on call or covering for another physician, the patient’s encounter is classified as it would have been by the The Office of the Inspector General (OIG) Work Plan for physicians physician who is not available. Thus, a locum tenens physician who consistently lists these codes as an area of continued investigative sees a patient on behalf of the patient’s attending physician may not review. This is primarily because Medicare payments for these bill a new patient code unless the attending physician has not seen services total approximately $32 billion per year and are responsible the patient for any problem within three years. for close to half of Medicare payments for physician services. Hospital observation services are E/M services provided to patients The levels of E/M services define the wide variations in skill, effort, who are designated or admitted as “observation status” in a and time and are required for preventing and/or diagnosing and hospital. treating illness or injury, and promoting optimal health. These codes are intended to represent physician work, and because much of this Codes 99218-99220 are used to indicate initial observation care. work involves the amount of training, experience, expertise, and These codes include the initiation of the observation status, knowledge that a provider may bring to bear on a given patient supervision of patient care including writing orders, and the presentation, the true indications of the level of this work may be performance of periodic reassessments. These codes are used only difficult to recognize without some explanation. by the physician “admitting” the patient for observation.

At first glance, selecting an E/M code may appear to be difficult, but Codes 99234-99236 are used to indicate evaluation and the system of coding clinical visits may be mastered once the management services to a patient who is admitted to and requirements for code selection are learned and used. discharged from observation status or hospital inpatient on the same day. If the patient is admitted as an inpatient from observation on the same day, use the appropriate level of Initial Hospital Care Types of E/M Services (99221-99223). When approaching E/M, the first choice that a provider must make Code 99217 indicates discharge from observation status. It includes is what type of code to use. The following tables outline the E/M the final physical examination of the patient, instructions, and codes for different levels of care for: preparation of the discharge records. It should not be used when • Office or other outpatient services—new patient admission and discharge are on the same date of service. As mentioned above, report codes 99234-99236 to appropriately • Office or other outpatient services—established patient describe same day observation services. • Hospital observation services—initial care, subsequent, and discharge If a patient is in observation longer than one day, subsequent • Hospital inpatient services—initial care, subsequent, and observation care codes 99224-99226 should be reported. If the discharge patient is discharged on the second day, observation discharge code 99217 should be reported. If the patient status is changed to • Observation or inpatient care (including admission and discharge inpatient on a subsequent date, the appropriate inpatient code, services) 99221-99233, should be reported. • Consultations—office or other outpatient • Consultations—inpatient Initial hospital care is defined as E/M services provided during the first hospital inpatient encounter with the patient by the admitting physician. (If a physician other than the admitting physician