Vascular Surgery a Comprehensive Illustrated Guide to Coding and Reimbursement

ATCR.book Page 1 Tuesday, November 20, 2012 3:07 PM

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

2015 ATCR.book Page i Tuesday, November 20, 2012 3:07 PM

Contents

Getting Started with Coding Companion ...... i Diaphragm ...... 586 Chest Wall ...... 1 Esophagus ...... 589 General Musculoskeletal ...... 2 Abdomen ...... 635 Neck and Thorax ...... 4 Thyroid Gland ...... 640 Larynx ...... 24 Parathyroid...... 641 Trachea and Bronchi ...... 28 Nervous System...... 644 Lungs and Pleura ...... 56 Medicine ...... 651 Heart and Pericardium ...... 129 Appendix...... 718 Arteries and Veins ...... 293 Evaluation and Management ...... 775 Lymph Nodes ...... 579 Index...... 795 Mediastinum ...... 582

CPT © 2013 American Medical Association. All Rights Reserved. © 2014 OptumInsight, Inc. Coding Companion for Cardiology/Cardiothoracic/Vascular Surgery Contents reported separately. Any additional repair or hypertension first: 402.0-402.9, with 33945 resection procedures on the donor heart are fifth-digit 1 or 404.0-404.9 with fifth 33945 Heart transplant, with or without recipient also reported separately, see 33300, 33310, digit 1 or 3) 33320, 33400, 33463, 33464, 33510, 33641, cardiectomy 428.22 Chronic systolic heart failure — (Code, 35216, 35276, or 35685. Donor cardiectomy and any backbench work, repair, or resection if applicable, heart failure due to procedures on the donor heart are usually the hypertension first: 402.0-402.9, with financial responsibility of the recipient. fifth-digit 1 or 404.0-404.9 with fifth digit 1 or 3) ICD-9-CM Procedural 428.32 Chronic diastolic heart failure — 00.93 Transplant from cadaver (Code, if applicable, heart failure due 37.51 Heart transplantation to hypertension first: 402.0-402.9, with fifth-digit 1 or 404.0-404.9 with 39.61 Extracorporeal circulation auxiliary to fifth digit 1 or 3) open heart surgery 428.42 Chronic combined systolic and Anesthesia diastolic heart failure — (Code, if 33945 00580 applicable, heart failure due to hypertension first: 402.0-402.9, with ICD-9-CM Diagnostic fifth-digit 1 or 404.0-404.9 with fifth 398.0 Rheumatic myocarditis digit 1 or 3) 412 Old myocardial infarction — (Use 429.0 Unspecified myocarditis — (Use additional code to identify presence additional code to identify presence of hypertension: 401.0-405.9) of arteriosclerosis) 414.00 Coronary atherosclerosis of 429.1 Myocardial degeneration — (Use unspecified type of vessel, native or additional code to identify presence graft — (Use additional code to of arteriosclerosis)

identify presence of hypertension: 429.2 Unspecified cardiovascular disease — Heart and Pericardium Explanation 401.0-405.9) (Use additional code to identify The patient is placed on cardiopulmonary 414.01 Coronary atherosclerosis of native presence of arteriosclerosis) bypass. Cardiac transplantation may be coronary artery — (Use additional 746.9 Unspecified congenital anomaly of performed by one of two techniques: total code to identify presence of heart orthotopic heart replacement or heterotropic hypertension: 401.0-405.9) implantation. A total orthotopic heart 414.02 Coronary atherosclerosis of CCI Version 18.3 replacement involves excising the ventricles, 0213T, 0216T, 0228T, 0230T, 12001-12007, autologous vein bypass graft — (Use atrial appendages, and most of the coronary 12011-12057, 13100-13153, 32100, 32422, additional code to identify presence sinus from the donor heart. The recipient heart 32551, 33210-33211, 33310-33315, 35226, is then opened. The atria, aorta, and of hypertension: 401.0-405.9) 36000, 36400-36410, 36420-36430, 36440, pulmonary artery of the recipient heart are 414.04 Coronary atherosclerosis of artery 36600, 36640, 37202, 39000-39010, 43752, anastomosed to the donor heart. The sinoatrial bypass graft — (Use additional code 51701-51703, 62310-62319, 64400-64435, nodes of both the donor and recipient heart to identify presence of hypertension: 64445-64450, 64479, 64483, 64490, 64493, are left intact. In a heterotropic implantation, 401.0-405.9) 64505-64530, 69990, 93000-93010, the donor's organs are placed by sewing the 93040-93042, 93318, 94002, 94200, 94250, 414.8 Other specified forms of chronic left atrium of the donor heart to the left atrium 94680-94690, 94770, 95812-95816, 95819, ischemic heart disease — (Use of the recipient, and then sewing together the 95822, 95829, 95955, 96360, 96365, 96372, atrial septums and the right atrium. The donor additional code to identify presence 96374-96376, 99148-99149, 99150 of hypertension: 401.0-405.9) aorta is then trimmed to an appropriate length Note: These CCI edits are used for Medicare. and sewn to the ascending aorta of the 422.91 Idiopathic myocarditis Other payers may reimburse on codes listed recipient. Immunosuppressive drugs may be 422.92 Septic myocarditis — (Use additional above. given to the patient before, during, and after code to identify infectious organism) the operation. Cardiopulmonary bypass is Medicare Edits discontinued when the donor heart begins 422.93 Toxic myocarditis Fac Non-Fac functioning in the recipient. 425.0 Endomyocardial fibrosis RVU RVU FUD Status 425.3 Coding Tips Endocardial fibroelastosis 33945 145.58 145.58 R90 425.4 Other primary cardiomyopathies Heart transplantation involves three distinct MUE Modifiers 428.0 Congestive heart failure, unspecified components. Code 33945 includes only 33945 8062*N/A511 transplant of the cadaver donor heart with or — (Code, if applicable, heart failure * with documentation without recipient cardiectomy and care of the due to hypertension first: Medicare References: 100-2,15,50.5; recipient. Cadaver cardiectomy (33940) is 402.0-402.9, with fifth-digit 1 or 100-2,15,60.3; 100-3,260.9; 100-4,3,90.2.1 reported separately. Backbench work (33944), 404.0-404.9 with fifth digit 1 or 3) which involves preparation of the cadaver 428.1 Left heart failure — (Code, if donor heart allograft prior to transplant, is also applicable, heart failure due to

CPT © 2013 American Medical Association. All Rights Reserved. © 2014 OptumInsight, Inc. Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery Heart and Pericardium — 279 Explanation Explanation 36400 A needle is inserted through the skin to puncture a The physician performs a push transfusion on a child 36400 Venipuncture, younger than age 3 years, vein of a person 3 years of age or older. The needle 2 years old and under. The physician calculates the necessitating the skill of a physician or is inserted into the vein and used for the withdrawal amount of blood to be transfused and slowly injects other qualified health care professional, of blood for diagnostic study or for the therapeutic it into the patient using a needle or existing infusion of intravenous medication. A soft flexible catheter. not to be used for routine venipuncture; catheter may be placed for prolonged therapy. Once femoral or jugular vein the procedure is complete, the needle or catheter 36450-36455 is withdrawn and pressure is applied over the 36450 Exchange transfusion, blood; newborn Explanation puncture site to control bleeding. Use this code 36455 other than newborn A needle is inserted through the skin to puncture when the venipuncture necessitates the skills of a the femoral or jugular vein of a child younger than physician or other qualified health care professional. age 3. The needle is inserted into the vein and used Do not use this code when routine venipuncture is Explanation for the withdrawal of blood for diagnostic study or performed. The physician performs an exchange transfusion on for the therapeutic infusion of intravenous a newborn. The physician calculates the blood medication. A soft flexible catheter may be placed Coding Tips volume to be transfused. A needle is placed in an for prolonged therapy. Once the procedure is This code has been revised for 2013 in the official artery or in an existing arterial catheter. The patient's complete, the needle or catheter is withdrawn and CPT description. blood is removed and replaced simultaneously to pressure is applied over the puncture site to control maintain blood pressure. Report 36455 if the child bleeding. Use this code for venipuncture when it is other than a newborn. necessitates the skill of a physician or other qualified 36415-36416 health care professional. Do not use this code when 36415 Collection of venous blood by routine venipuncture is performed. venipuncture 36510 36416 Collection of capillary blood specimen (eg, 36510 Catheterization of umbilical vein for Coding Tips finger, heel, ear stick) diagnosis or therapy, newborn This code has been revised for 2013 in the official CPT description. Explanation Explanation A needle is inserted into the skin over a vein to The physician catheterizes the umbilical vein for 36405-36406 puncture the blood vessel and withdraw blood for diagnostic or therapeutic purposes. The physician 36405 Venipuncture, younger than age 3 years, venous collection in 36415. In 36416, a prick is cleanses the umbilical cord stump and locates the necessitating the skill of a physician or made into the finger, heel, or ear and capillary blood umbilical vein. A catheter is inserted in the vein for other qualified health care professional, that pools at the puncture site is collected in a reasons including blood sampling or administering not to be used for routine venipuncture; pipette. In either case, the blood is used for medication. scalp vein diagnostic study and no catheter is placed. 36406 other vein 36660 36420-36425 36660 Catheterization, umbilical artery, newborn, Explanation 36420 Venipuncture, cutdown; younger than age for diagnosis or therapy A needle is inserted through the skin to puncture a 1 year vein of a child younger than age 3. In 36405, the 36425 age 1 or over Explanation scalp vein is punctured and in 36406, a vein other The physician catheterizes an umbilical artery in a than the femoral, jugular, or scalp vein is used. The Explanation newborn for diagnostic or therapeutic purposes. needle is inserted into the vein and used for the The physician prepares the umbilical artery and withdrawal of blood or for the therapeutic infusion The physician makes an incision in the skin directly passes a catheter sheath inside the lumen for arterial of intravenous medication. A soft flexible catheter over the vessel and dissects the area surrounding access. The catheter is attached to a pressure line may be placed for prolonged therapy. Once the the vein. A needle is passed into the vein for the that maintains patency of the arterial lumen. The procedure is complete, the needle or catheter is withdrawal of blood or for the infusion of access is used for diagnostic or therapeutic purposes, withdrawn and pressure is applied over the puncture intravenous medication of a patient under 12 allowing the drawing of blood for tests or instillation site to control bleeding. Use these codes when months of age (in 36420) or over 12 months of age of medication. venipuncture necessitates the skill of a physician or (in 36425). A catheter may be left behind. Once other qualified health care professional. Do not use the procedure is complete, the incision is repaired 70373 these codes when routine venipuncture is with a layered closure. 70373 Laryngography, contrast, radiological performed. 36430 supervision and interpretation Coding Tips 36430 Transfusion, blood or blood components These codes have been revised for 2013 in the Explanation Appendix official CPT description. Explanation A radiographic contrast study is performed of the larynx, or organ of voice. Iodized oil is given in The physician transfuses blood or blood components conjunction with the examination via tubing, which 36410 to a patient. The physician establishes venous access allows oil to drip down the patient's throat at the 36410 Venipuncture, age 3 years or older, with a needle and catheter and transfuses the blood radiologists discretion. The radiologist, via x-ray necessitating the skill of a physician or products. fluoroscopy, simultaneously watches the image other qualified health care professional amplified and displayed on a TV monitor. Rapid film (separate procedure), for diagnostic or 36440 sequencing must be used to record the image, therapeutic purposes (not to be used for 36440 Push transfusion, blood, 2 years or younger which may then be studied and interpreted by the routine venipuncture) radiologist.

© 2014 OptumInsight, Inc. CPT © 2013 American Medical Association. All Rights Reserved. 718 — Appendix Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery ATCR.book Page 775 Tuesday, N ovem ber 20, 2012 3:07 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