Coding Companion for Plastics/Dermatology a Comprehensive Illustrated Guide to Coding and Reimbursement

ATPR.book Page 1 Thursday, N ovem ber 15, 2012 3:09 PM

Coding Companion for Plastics/Dermatology A comprehensive illustrated guide to coding and reimbursement

2013 ATPR.book Page i Thursday, N ovem ber 15, 2012 3:09 PM

Contents

Getting Started with Coding Companion ...... i Arteries/Veins...... 365 Skin ...... 1 Lips ...... 368 Nails ...... 30 Vestibule of Mouth ...... 381 Pilonidal Cyst...... 34 Tongue...... 384 Repair ...... 35 Palate/Uvula ...... 388 Destruction...... 131 Abdomen ...... 402 Breast ...... 144 Genitalia...... 403 General Musculoskeletal ...... 167 Extracranial Nerves ...... 407 Head...... 181 Ocular Adnexa...... 428 Neck/Thorax...... 296 External Ear ...... 453 Shoulder...... 301 Operating Microscope...... 457 Humerus/Elbow ...... 303 Medicine Services ...... 458 Forearm/Wrist...... 306 Appendix...... 463 Hand/Fingers ...... 321 CCI Edits ...... 474 Endoscopy...... 354 Evaluation and Management ...... 477 Nose...... 357 Index...... 499

CPT only © 2012 American Medical Association. All Rights Reserved. © 2012 OptumInsight, Inc. Coding Companion for Plastics/Dermatology Contents ICD-9-CM Diagnostic 801.60 Open fracture of base of skull with cerebral laceration and contusion, 21340 801.00 Closed fracture of base of skull 21340 unspecified state of consciousness Percutaneous treatment of nasoethmoid without mention of intracranial injury, complex fracture, with splint, wire or unspecified state of consciousness 801.61 Open fracture of base of skull with headcap fixation, including repair of cerebral laceration and contusion, no 801.01 Closed fracture of base of skull canthal ligaments and/or the nasolacrimal loss of consciousness without mention of intracranial injury, apparatus no loss of consciousness 801.62 Open fracture of base of skull with cerebral laceration and contusion, 801.02 Closed fracture of base of skull brief (less than one hour) loss of without mention of intracranial injury, consciousness brief (less than one hour) loss of consciousness 801.63 Open fracture of base of skull with cerebral laceration and contusion, 801.03 Closed fracture of base of skull moderate (1-24 hours) loss of without mention of intracranial injury, consciousness moderate (1-24 hours) loss of consciousness Terms To Know 801.04 Closed fracture of base of skull without mention of intracranial injury, fracture. Break in bone or cartilage. prolonged (more than 24 hours) loss incision. Act of cutting into tissue or an of consciousness and return to organ. pre-existing conscious level 801.05 Closed fracture of base of skull CCI Version 18.3 without mention of intracranial injury, 0213T, 0216T, 0228T, 0230T, 12001-12007, prolonged (more than 24 hours) loss 12011-12057, 13100-13153, 21280, of consciousness, without return to 21337-21338, 36000, 36400-36410, pre-existing conscious level 36420-36430, 36440, 36600, 36640, 37202, 43752, 51701-51703, 62310-62319, 801.06 Closed fracture of base of skull 64400-64435, 64445-64450, 64479, 64483, without mention of intracranial injury, 64490, 64493, 64505-64530, 69990, loss of consciousness of unspecified 93000-93010, 93040-93042, 93318, 94002, Explanation duration 94200, 94250, 94680-94690, 94770, 801.09 Closed fracture of base of skull 95812-95816, 95819, 95822, 95829, 95955, The physician repairs fractures of the without mention of intracranial injury, 96360, 96365, 96372, 96374-96376, nasoethmoid region with percutaneous 97597-97598, 97602-97606, 99148-99149, unspecified concussion (through the skin) approaches. Percutaneous 99150 801.11 Closed fracture of base of skull with pins or screws are placed into stable bone and Note: These CCI edits are used for Medicare. attached to external support such as splints, cerebral laceration and contusion, no Other payers may reimburse on codes listed headcaps, or wire fixation to aid in reduction loss of consciousness above. of the fractures. If the medial canthal 801.12 Closed fracture of base of skull with ligaments are detached, they are repaired cerebral laceration and contusion, Medicare Edits through a percutaneous approach with awls brief (less than one hour) loss of Fac Non-Fac or K-wires and transnasal stainless steel sutures consciousness RVU RVU FUD Status or wire. Injuries of the nasolacrimal complex 21340 24.27 24.27 90 A are repaired using non-resorbable sutures and 801.13 Closed fracture of base of skull with Head polyethylene tubing. cerebral laceration and contusion, MUE Modifiers moderate (1-24 hours) loss of 21340 1 51 N/A N/A 80* Coding Tips consciousness * with documentation For open treatment of a nasoethmoid fracture, 801.50 Open fracture of base of skull without Medicare References: None with or without external fixation, see 21338 mention of intracranial injury, and 21339. For radiology services, see unspecified state of consciousness 70140–70170. 801.51 Open fracture of base of skull without mention of intracranial injury, no loss ICD-9-CM Procedural of consciousness 21.71 Closed reduction of nasal fracture 801.52 Open fracture of base of skull without 76.78 Other closed reduction of facial mention of intracranial injury, brief fracture (less than one hour) loss of consciousness Anesthesia 801.53 Open fracture of base of skull without 21340 00160 mention of intracranial injury, moderate (1-24 hours) loss of consciousness

CPT only © 2012 American Medical Association. All Rights Reserved. © 2012 OptumInsight, Inc. Coding Companion for Plastics/Dermatology Head — 263 are AP axial (front to back), lateral, and PA axial patient must remain still while lying on a motorized 70100-70110 (back to front). X-rays may be taken with the patient table within the large, circular MRI tunnel. A sedative placed erect, prone, or supine and either code may may be administered as well as contrast material for 70100 Radiologic examination, mandible; partial, include stereoradiography, which is a technique image enhancement. This code reports an exam of less than 4 views that produces three-dimensional images. the temporomandibular joint(s).

70110 complete, minimum of 4 views Appendix Explanation 70300-70320 70350 70300 Radiologic examination, teeth; single view 70350 Cephalogram, orthodontic The lower jaw bone is x-rayed. In 70100, three or 70310 partial examination, less than full less projections are taken for a partial view of the mouth Explanation bone structure and in 70110, four or more 70320 projections are taken for a complete view of the complete, full mouth A lateral or frontal x-ray projection is taken to bone structure. examine the entire skull, jaw, and related tooth Explanation positions. The machine holds the patient's head in Films are taken of the mouth to show teeth and/or the same position each time so that a series of 70140 cephalograms can be directly compared for growth 70140 Radiologic examination, facial bones; less surrounding bone. In dental radiography, the film may be placed either inside or outside the mouth. and development over time. than 3 views Code 70300 reports a single view only, 73010 Explanation reports a partial examination, and 70320 reports a 70355 complete full mouth exam. 70355 Orthopantogram (eg, panoramic x-ray) X-rays of the facial bones are obtained to determine an injury, fracture, or neoplasm. After positioning 70328-70330 Explanation the patient, less than three views of the facial bones 70328 Radiologic examination, A panoramic radiographic study is performed on are obtained. The physician supervises the the mandibular arch and its supporting structures. procedure and interprets and reports the findings. temporomandibular joint, open and closed mouth; unilateral A single image is produced of the mandible for diagnostic purposes. The physician evaluates 70330 bilateral 70150 trauma, third molar, and other unique disease 70150 Radiologic examination, facial bones; Explanation conditions. Tooth development and anomalies may complete, minimum of 3 views also be studied. The temporomandibular joint is x-rayed in two Explanation projections on one side only in 70328 and in two 70450-70470 projections on both sides in 70330. One film is taken 70450 Computed tomography, head or brain; X-rays of the facial bones are obtained to determine with the mouth open and one with the mouth an injury, fracture, or neoplasm. After positioning closed. without contrast material the patient, a complete series of x-rays of the facial 70460 with contrast material(s) bones, with a minimum of three views, is obtained. 70332 70470 without contrast material, followed by The physician supervises the procedure and contrast material(s) and further sections interprets and reports the findings. 70332 Temporomandibular joint arthrography, radiological supervision and interpretation Explanation 70160 Explanation Computerized axial tomography directs multiple 70160 Radiologic examination, nasal bones, narrow beams of x-rays around the body structure complete, minimum of 3 views A radiographic contrast study is performed on the being studied and uses computer imaging to temporomandibular joint. A contrast material is produce thin cross-sectional views of various layers Explanation injected into the joint spaces, followed by x-ray (or slices) of the body. It is useful for the evaluation examination of the joint. This allows the physician of trauma, tumor, and foreign bodies as CT is able Films are taken of the nasal bones to include a to see the position of the structures not normally to visualize soft tissue as well as bones. Patients are complete exam, or minimum of three views. seen on conventional x-rays. required to remain motionless during the study and Typically, this exam would consist of both right and sedation may need to be administered as well as a left lateral (side to side) for comparison, as well as contrast medium for image enhancement. These a tangential projection in which the x-ray beam is 70336 codes report an exam of the head or brain. Report directed from a position above the patient's head 70336 Magnetic resonance (eg, proton) imaging, 70450 if no contrast is used. Report 70460 if down through the nose. This view is primarily used temporomandibular joint(s) performed with contrast and 70470 if performed to demonstrate the medial or lateral (side to side) first without contrast and then again following the displacement of nasal fractures. Explanation injection of contrast. Magnetic resonance imaging (MRI) is a 70250-70260 radiation-free, noninvasive, technique to produce 70480-70482 70250 Radiologic examination, skull; less than 4 high quality sectional images of the inside of the 70480 Computed tomography, orbit, sella, or views body in multiple planes. MRI uses the natural posterior fossa or outer, middle, or inner 70260 complete, minimum of 4 views magnetic properties of the hydrogen atoms in our bodies that emit radiofrequency signals when ear; without contrast material Explanation exposed to radio waves within a strong 70481 with contrast material(s) electro-magnetic field. These signals are then 70482 without contrast material, followed by Films are taken of the skull bones. In 70250, three processed and converted by the computer into contrast material(s) and further sections or less views are taken, and in 70260, a complete high-resolution, three-dimensional, tomographic exam with a four view minimum is performed. The images. Patients with metallic or electronic implants most common projections for routine skull series or foreign bodies cannot be exposed to MRI. The

CPT only © 2012 American Medical Association. All Rights Reserved. © 2012 OptumInsight, Inc. Coding Companion for Plastics/Dermatology Appendix — 463 ATPR.book Page 477 Thursd ay , N ovem ber 15, 2012 3:09 PM

Evaluation and Management Evaluation and Management

This section provides an overview of evaluation and management guidelines. The qualified health care professional may report services (E/M) services, tables that identify the documentation elements independently or under incident-to guidelines. The professionals associated with each code, and the federal documentation within this definition are separate from “clinical staff" and are able to guidelines with emphasis on the 1997 exam guidelines. This set of practice independently. CPT defines clinical staff as “a person who guidelines represent the most complete discussion of the elements works under the supervision of a physician or other qualified health of the currently accepted versions. The 1997 version identifies both care professional and who is allowed, by law, regulation, and facility general multi-system physical examinations and single-system policy to perform or assist in the performance of a specified examinations, but providers may also use the original 1995 version professional service, but who does not individually report that of the E/M guidelines; both are currently supported by the Centers professional service.” Keep in mind that there may be other policies for Medicare and Medicaid Services (CMS) for audit purposes. or guidance that can affect who may report a specific service.

Although some of the most commonly used codes by physicians of all specialties, the E/M service codes are among the least Types of E/M Services understood. These codes, introduced in the 1992 CPT® manual, When approaching E/M, the first choice that a provider must make were designed to increase accuracy and consistency of use in the is what type of code to use. The following tables outline the E/M reporting of levels of non-procedural encounters. This was codes for different levels of care for: accomplished by defining the E/M codes based on the degree that certain common elements are addressed or performed and reflected • Office or other outpatient services—new patient in the medical documentation. • Office or other outpatient services—established patient The Office of the Inspector General (OIG) Work Plan for physicians • Hospital observation services—initial care, subsequent, and consistently lists these codes as an area of continued investigative discharge review. This is primarily because Medicare payments for these • Hospital inpatient services—initial care, subsequent, and services total approximately $32 billion per year and are responsible discharge for close to half of Medicare payments for physician services. • Observation or inpatient care (including admission and discharge services) The levels of E/M services define the wide variations in skill, effort, and time and are required for preventing and/or diagnosing and • Consultations—office or other outpatient treating illness or injury, and promoting optimal health. These codes • Consultations—inpatient are intended to represent physician work, and because much of this work involves the amount of training, experience, expertise, and The specifics of the code components that determine code selection knowledge that a provider may bring to bear on a given patient are listed in the table and discussed in the next section. Before a presentation, the true indications of the level of this work may be level of service is decided upon, the correct type of service is difficult to recognize without some explanation. identified.

At first glance, selecting an E/M code may appear to be difficult, but Office or other outpatient services are E/M services provided in the the system of coding clinical visits may be mastered once the physician or other qualified health care provider’s office, the requirements for code selection are learned and used. outpatient area, or other ambulatory facility. Until the patient is admitted to a health care facility, he/she is considered to be an Providers outpatient. The AMA advises coders that while a particular service or procedure A new patient is a patient who has not received any face-to-face may be assigned to a specific section, the service or procedure itself professional services from the physician or other qualified health is not limited to use only by that specialty group (see paragraphs 2 care provider within the past three years. An established patient is a and 3 under “Instructions for Use of the CPT Codebook” on page x patient who has received face-to-face professional services from the of the CPT Book). Additionally, the procedures and services listed physician or other qualified health care provider within the past throughout the book are for use by any qualified physician or other three years. In the case of group practices, if a physician or other qualified health care professional or entity (e.g., hospitals, qualified health care provider of the exact same specialty or laboratories, or home health agencies). subspecialty has seen the patient within three years, the patient is considered established. The use of the phrase “physician or other qualified health care professional” (OQHCP) was adopted to identify a health care If a physician or other qualified health care provider is on call or provider other than a physician. This type of provider is further covering for another physician or other qualified health care described in CPT as an individual “qualified by education, training, provider, the patient’s encounter is classified as it would have been licensure/regulation (when applicable), and facility privileging by the physician or other qualified health care provider who is not (when applicable)” State licensure guidelines determine the scope available. Thus, a locum tenens physician or other qualified health of practice and a qualified health care professional must practice care provider who sees a patient on behalf of the patient’s attending within these guidelines, even if more restrictive than the CPT physician or other qualified health care provider may not bill a new