General Surgery/ Gastroenterology a Comprehensivesample Illustrated Guide to Coding and Reimbursement

CODING COMPANION

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2018 General Surgery/ Gastroenterology A comprehensiveSample illustrated guide to coding and reimbursement

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Getting Started with Coding Companion ...... i Esophagus ...... 288 Skin ...... 1 Stomach ...... 385 Pilonidal Cyst ...... 35 Intestines...... 436 Introduction...... 36 Meckel’s Diverticulum...... 545 Repair ...... 42 Appendix ...... 548 Destruction ...... 90 Rectum ...... 551 Breast...... 96 Anus ...... 629 General Musculoskeletal ...... 121 Liver...... 674 Neck...... 134 Biliary Tract...... 694 Back...... 138 Pancreas ...... 731 Spine...... 141 Abdomen/Digestive...... 750 Abdomen/Musculoskeletal...... 142 Testis...... 820 Humerus ...... 144 Tunica Vaginalis...... 824 Forearm/Wrist...... 148 Vas Deferens...... 827 Hands/Fingers ...... 152 Spermatic Cord/Seminal Vesicles ...... 829 Pelvis/Hip...... 154 Reproductive...... 834 Femur/Knee ...... 162 Thyroid...... 835 Leg/Ankle ...... 165 Parathyroid ...... 845 Foot/Toes...... 169 Extracranial Nerves...... 850 Endoscopy...... 171 Medicine ...... 856 Respiratory...... 172 HCPCS ...... 870 Arteries and Veins...... 182 Appendix ...... 881 Spleen...... 251 Correct Coding Initiative Update 22.3 ...... 923 Lymph Nodes ...... 255 Evaluation and Management ...... 943 Diaphragm ...... 283 Index ...... page 963

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Coding Companion for General Surgery/Gastroenterology is designed CCI Edit Updates to be a guide to the specialty procedures classified in the CPT® book. The Coding Companion series includes the list of codes from the It is structured to help coders understand procedures and translate official Centers for Medicare and Medicaid Services’ National Correct physician narrative into correct CPT codes by combining many Coding Policy Manual for Part B Medicare Contractors that are clinical resources into one, easy-to-use source book. considered to be an integral part of the comprehensive code or The book also allows coders to validate the intended code selection mutually exclusive of it and should not be reported separately. The by providing an easy-to-understand explanation of the procedure codes in the Correct Coding Initiative (CCI) section are from version and associated conditions or indications for performing the various 22.3, the most current version available at press time. The CCI edits procedures. As a result, data quality and reimbursement will be are located in a section at the back of the book. Optum360 improved by providing code-specific clinical information and maintains a website to accompany the Coding Companions series helpful tips regarding the coding of procedures. and posts updated CCI edits on this website so that current information is available before the next edition. The website address For ease of use, Coding Companion lists the CPT codes in ascending is http://www.optum360coding.com/ProductUpdates/. The 2017 numeric order. Included in the code set are all surgery, radiology, edition password is: SPEC17DLC. Please note that you should log in laboratory, medicine, and evaluation and management (E/M) codes each quarter to ensure you receive the most current updates. An pertinent to the specialty. Each CPT code is followed by its official email reminder will also be sent to you to let you know when the CPT code description. updates are available. Resequencing of CPT Codes Evaluation and Management The American Medical Association (AMA) employs a resequenced This resource provides documentation guidelines and tables numbering methodology. According to the AMA, there are instances showing evaluation and management (E/M) codes for different where a new code is needed within an existing grouping of codes, levels of care. The components that should be considered when but an unused code number is not available to keep the range selecting an E/M code are also indicated. sequential. In the instance where the existing codes were not changed or had only minimal changes, the AMA assigned a code out Index of numeric sequence with the other related codes being grouped A comprehensive index is provided for easy access to the codes. The together. The resequenced codes and their descriptions have been index entries have several axes. A code can be looked up by its placed with their related codes, out of numeric sequence. procedural name or by the diagnoses commonly associated with it. Codes are also indexed anatomically. For example: CPT codes within the Optum360 Coding Companion series display in their resequenced order. Resequenced codes are enclosed in 69501 Transmastoidpage antrotomy (simple mastoidectomy) brackets for easy identification. could be found in the index under the following main terms: ICD-10-CM Antrotomy Overall, the 10th revision goes into greater clinical detail than did Transmastoid, 69501 ICD-9-CM and addresses information about previously classified diseases, as well as those diseases discovered since the last revision. Excision Conditions are grouped with general epidemiological purposes and Mastoid the evaluation of health care in mind. New features have been Simple, 69501 added, and conditions have been reorganized, although the format General Guidelines and conventions of the classification remain unchanged for the most part. Providers The AMA advises coders that while a particular service or procedure Detailed Code Information may be assigned to a specific section, the service or procedure itself One or more columns are dedicated to each procedure or service or is not limited to use only by that specialty group (see paragraphs to a series of similar procedures/services. Following the specific CPT two and three under “Instructions for Use of the CPT Codebook” on code and its narrative, is a combination of features. A sample is page xii of the CPT Book). Additionally, the procedures and services shown on page ii. The black boxes with numbers in them listed throughout the book are for use by any qualified physician or correspond to the information on the page following the sample. other qualified health care professional or entity (e.g., hospitals, Appendix Codes and Descriptions laboratories, or home health agencies). Keep in mind that there may be other policies or guidance that can affect who may report a Some CPT codes are presented in a less comprehensive format in the specific service. appendix. The CPT codes appropriate to the specialty are included in the appendix with the official CPT code description. The codes are Supplies presented in numeric order, and each code is followed by an Some payers may allow physicians to separately report drugs and easy-to-understand lay description of the procedure. other supplies when reporting the place of service as office or other The codes in the appendix are presented in the following order: nonfacility setting. Drugs and supplies are to be reported by the Samplefacility only when performed in a facility setting. •Category III Professional and Technical Component •Radiology Radiology and some pathology codes have a technical and a • Pathology and Laboratory professional component. When physicians do not own their own • Medicine Services equipment and send their patients to outside testing facilities, they should append modifier 26 to the procedural code to indicate they Category II codes are not published in this book. Refer to the CPT performed only the professional component. book for code descriptions.

CPT1 © 20 7 American Medical Association. All Rights Reserved. © 2017 Optum360, LLC Coding Companion for General Surgery/Gastroenterology Getting Started with Coding Companion — i 21501-21502 Terms To Know abscess. Circumscribed collection of pus resulting from bacteria, frequently 21501 Incision and drainage, deep abscess or hematoma, soft tissues of associated with swelling and other signs of inflammation. neck or thorax; blunt dissection. Surgical technique used to expose an underlying area by 21502 with partial rib ostectomy separating along natural cleavage lines of tissue, without cutting. Skin, fat, cellulitis. Sudden, severe, suppurative inflammation and edema in and subfascial subcutaneous tissue or muscle, most often caused by bacterial infection tissues secondary to a cutaneous lesion. fascia. Fibrous sheet or band of tissue that envelops organs, muscles, and groupings of muscles. Platysma muscle hematoma. Tumor-like collection of blood in some part of the body caused by a break in a blood vessel wall, usually as a result of trauma. incision and drainage. Cutting open body tissue for the removal of tissue fluids or infected discharge from a wound or cavity. A deep abscess or hematoma is drained irrigation. To wash out or cleanse a body cavity, wound, or tissue with water or other fluid. myotomy. Surgical cutting of a muscle to gain access to underlying tissues or for therapeutic reasons. seroma. Swelling caused by the collection of serum, or clear fluid, in the tissues. soft tissue. Nonepithelial tissues outside of the skeleton that includes subcutaneous adipose tissue, fibrous tissue, fascia, muscles, blood and lymph Explanation vessels, and peripheral nervous system tissue. The physician performs surgery to remove or drain an abscess or hematoma page subcutaneous tissue. Sheet or wide band of adipose (fat) and areolar from the deep soft tissues of the neck or thorax. With proper anesthesia administered, the physician makes an incision overlying the site of the abscess connective tissue in two layers attached to the dermis. or hematoma of the neck or thorax. Dissection is carried down through the Medicare Edits deep subcutaneous tissues and may be continued into the fascia or muscle to expose the abscess or hematoma. The incision may be extended if the mass Fac RVU Non-Fac RVU FUD Status MUE is larger than expected. The abscess or hematoma is incised and the contents 21501 9.21 12.91 90 A 3(3) are drained. The area is irrigated and the incision is repaired in layers with 21502 14.61 14.61 90 A 1(3) sutures, staples, and/or Steri-strips, closed with drains in place, or simply left open to further facilitate drainage of infection. Report 21502 if a partial rib ostectomy is performed during this procedure. Modifiers Medicare Reference Coding Tips 21501 51 N/A N/A N/A None For posterior spine subfascial incision and drainage, see 22010–22015. If 21502 51 N/A N/A 80 significant additional time and effort are documented, append modifier 22 * with documentation and submit a cover letter and operative report. For a soft tissue biopsy of the of the neck or thorax, see 21550. ICD-10-CM Diagnostic Codes L03.221 Cellulitis of neck L03.312 Cellulitis of back [any part except buttock] Neck L03.313 Cellulitis of chest wall S10.83XA Contusion of other specified part of neck, initial encounter S20.211A ContusionSample of right front wall of thorax, initial encounter S20.212A Contusion of left front wall of thorax, initial encounter T81.4XXA Infection following a procedure, initial encounter HCPCS Equivalent Codes N/A

© 2017 Optum360, LLC CPT © 2017 American Medical Association. All Rights Reserved. 134 — Neck Coding Companion for General Surgery/Gastroenterology Evaluation and Management Evaluation and Management This section provides an overview of evaluation and management • Observation or inpatient care (including admission and discharge (E/M) services, tables that identify the documentation elements services) associated with each code, and the federal documentation • Consultations—office or other outpatient guidelines with emphasis on the 1997 exam guidelines. This set of guidelines represent the most complete discussion of the elements • Consultations—inpatient of the currently accepted versions. The 1997 version identifies both • Emergency department services general multi-system physical examinations and single-system • Critical care examinations, but providers may also use the original 1995 version • Nursing facility—initial services of the E/M guidelines; both are currently supported by the Centers for Medicare and Medicaid Services (CMS) for audit purposes. • Nursing facility—subsequent services The levels of E/M services define the wide variations in skill, effort, • Nursing facility—discharge and annual assessment and time and are required for preventing and/or diagnosing and • Domiciliary, rest home, or custodial care—new patient treating illness or injury, and promoting optimal health. These codes • Domiciliary, rest home, or custodial care—established patient are intended to represent physician work, and because much of this • Home services—new patient work involves the amount of training, experience, expertise, and knowledge that a provider may employ when treating a given • Home services—established patient patient, the true indications of the level of this work may be difficult • Newborn care services to recognize without some explanation. • Neonatal and pediatric interfacility transport At first glance, selecting an E/M code may appear to be difficult, but • Neonatal and pediatric critical care—inpatient the system of coding clinical visits may be mastered once the • Neonate and infant intensive care services—initial and requirements for code selection are learned and used. continuing Providers The AMA advises coders that while a particular service or procedure The specifics of the code components that determine code selection may be assigned to a specific section, the service or procedure itself are listed in the table and discussed in the next section. Before a is not limited to use only by that specialty group (see paragraphs 2 level of service is decided upon, the correct type of service is and 3 under “Instructions for Use of the CPT® Codebook” on page xii identified. of the CPT Book). Additionally, the procedures and services listed A new patient is a patient who has not received any face-to-face throughout the book are for use by any qualified physician or other professional servicespage from the physician or other qualified health qualified health care professional or entity (e.g., hospitals, care provider within the past three years. An established patient is a laboratories, or home health agencies). patient who has received face-to-face professional services from the The use of the phrase “physician or other qualified health care physician or other qualified health care provider within the past professional” (OQHCP) was adopted to identify a health care three years. In the case of group practices, if a physician or other provider other than a physician. This type of provider is further qualified health care provider of the exact same specialty or described in CPT as an individual “qualified by education, training, subspecialty has seen the patient within three years, the patient is licensure/regulation (when applicable), and facility privileging considered established. (when applicable).” State licensure guidelines determine the scope If a physician or other qualified health care provider is on call or of practice and a qualified health care professional must practice covering for another physician or other qualified health care within these guidelines, even if more restrictive than the CPT provider, the patient’s encounter is classified as it would have been guidelines. The qualified health care professional may report by the physician or other qualified health care provider who is not services independently or under incident-to guidelines. The available. Thus, a locum tenens physician or other qualified health professionals within this definition are separate from “clinical staff" care provider who sees a patient on behalf of the patient’s attending and are able to practice independently. CPT defines clinical staff as physician or other qualified health care provider may not bill a new “a person who works under the supervision of a physician or other patient code unless the attending physician or other qualified qualified health care professional and who is allowed, by law, health care provider has not seen the patient for any problem within regulation, and facility policy to perform or assist in the three years. performance of a specified professional service, but who does not individually report that professional service.” Keep in mind that Office or other outpatient services are E/M services provided in the there may be other policies or guidance that can affect who may physician or other qualified health care provider’s office, the report a specific service. outpatient area, or other ambulatory facility. Until the patient is admitted to a health care facility, he/she is considered to be an Types of E/M Services outpatient. Hospital observation services are E/M services provided When approaching E/M, the first choice that a provider must make is to patients who are designated or admitted as “observation status” what type of code to use. The following tables outline the E/M codes in a hospital. for different levels of care for: SampleCodes 99218-99220 are used to indicate initial observation care. • Office or other outpatient services—new patient These codes include the initiation of the observation status, • Office or other outpatient services—established patient supervision of patient care including writing orders, and the performance of periodic reassessments. These codes are used only • Hospital observation services—initial care, subsequent, and by the provider “admitting” the patient for observation. discharge • Hospital inpatient services—initial care, subsequent, and Codes 99234-99236 are used to indicate evaluation and discharge management services to a patient who is admitted to and