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Coding Companion ASPC.book Page 1 Wednesday, November 26, 2014 4:03 PM Coding Companion A comprehensive illustrated guide to coding and reimbursement 00 ASPC TOC.fm Page i Monday, December 1, 2014 1:24 PM Contents 2015 2015 Coding Companion Contents M71.052 Abscess of bursa, left hip 20005 M71.061 Abscess of bursa, right knee M71.062 Abscess of bursa, left knee 20005 Incision and drainage of soft tissue abscess, subfascial (ie, involves M71.071 Abscess of bursa, right ankle and foot the soft tissue below the deep fascia) M71.072 Abscess of bursa, left ankle and foot M71.08 Abscess of bursa, other site M71.09 Abscess of bursa, multiple sites M72.2 Plantar fascial fibromatosis M72.6 Necrotizing fasciitis M72.8 Other fibroblastic disorders N61 Inflammatory disorders of breast HCPCS Equivalent Codes N/A Terms To Know abscess. Circumscribed collection of pus resulting from bacteria, frequently Musculoskeletal associated with swelling and other signs of inflammation. osteomyelitis. Inflammation of bone that may remain localized or spread to the marrow, cortex, or periosteum, in response to an infecting organism, General usually bacterial and pyogenic. psoas. Muscles of the loins, the part of the side and back between the ribs and the pelvis. Explanation soft tissue. Nonepithelial tissues outside of the skeleton that includes subcutaneous adipose tissue, fibrous tissue, fascia, muscles, blood and lymph The physician makes an incision through skin and fascia directly over an vessels, and peripheral nervous system tissue. abscessed area involving the soft tissue below the deep fascia. The abscess cavity is explored, debrided, and drained. Depending on the appearance of subfascial. Beneath the band of fibrous tissue that lies deep to the skin, the area, the physician may place a drain or packing after copious irrigation encloses muscles, and separates their layers. of the area. Medicare Edits Coding Tips Fac RVU Non-Fac RVU FUD Status MUE For incision and drainage of an abscess of the skin and subcutaneous tissue, 20005 6.69 8.76 10 A 4(3) simple or single, see 10060; complicated or multiple, see 10061. It is inappropriate to report supplies when these services are performed in an emergency room. For physician office, supplies may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine Modifiers Medicare Reference coverage. 20005 51 N/A N/A N/A None * with documentation ICD-10-CM Diagnostic Codes K61.0 Anal abscess K61.1 Rectal abscess K61.2 Anorectal abscess K61.3 Ischiorectal abscess K65.1 Peritoneal abscess K68.12 Psoas muscle abscess M71.011 Abscess of bursa, right shoulder M71.012 Abscess of bursa, left shoulder M71.021 Abscess of bursa, right elbow M71.022 Abscess of bursa, left elbow M71.031 Abscess of bursa, right wrist M71.032 Abscess of bursa, left wrist M71.041 Abscess of bursa, right hand M71.042 Abscess of bursa, left hand M71.051 Abscess of bursa, right hip © 2015 Optum360, LLC CPT © 2015 American Medical Association. All Rights Reserved. 2 — General Musculoskeletal Coding Companion I09.2 Chronic rheumatic pericarditis 33010-33011 I24.1 Dressler's syndrome I30.0 Acute nonspecific idiopathic pericarditis 33010 Pericardiocentesis; initial I30.1 Infective pericarditis 33011 subsequent I30.8 Other forms of acute pericarditis I31.0 Chronic adhesive pericarditis Trachea I31.1 Chronic constrictive pericarditis I31.2 Hemopericardium, not elsewhere classified I31.3 Pericardial effusion (noninflammatory) I31.4 Cardiac tamponade I31.8 Other specified diseases of pericardium I32 Pericarditis in diseases classified elsewhere I51.7 Cardiomegaly M32.12 Pericarditis in systemic lupus erythematosus S26.01XA Contusion of heart with hemopericardium, initial encounter S26.09XA Other injury of heart with hemopericardium, initial encounter T86.31 Heart-lung transplant rejection T86.32 Heart-lung transplant failure T86.33 Heart-lung transplant infection T86.39 Other complications of heart-lung transplant HCPCS Equivalent Codes N/A Explanation Terms To Know The physician drains fluid from the pericardial space. The physician may cardiomegaly. Enlargement of the heart due to a thickened heart muscle or perform this procedure using anatomic landmarks or under fluoroscopic or an enlarged heart chamber, usually as a result of the heart having to work echocardiographic (ultrasound) guidance (separately reported). The physician harder than normal. places a long needle below the sternum and directs it into the pericardial space. When pericardial fluid is aspirated, the physician may advance a echography. Radiographic imaging that uses sound waves reflected off the guidewire through the needle into the pericardial space and exchange the different densities of anatomic structures to create images. needle over the guidewire for a drainage catheter. The physician removes as Arteries pericarditis. Inflammation affecting the pericardium. much pericardial fluid as is required, removes the needle or catheter, and dresses the wound. Report 33011 for each subsequent pericardiocentesis. pericardium. Thin and slippery case in which the heart lies that is lined with fluid so that the heart is free to pulse and move as it beats. Coding Tips and tamponade heart. Interference with the venous return of blood to the heart Moderate (conscious) sedation performed with 33010–33011 is considered due to an extensive accumulation of blood in the pericardium (pericardial to be an integral part of the procedure and is not reported separately. However, Veins effusion). Tamponade may occur as a complication of dissecting thoracic anesthesia services (00100–01999) may be billed separately when performed by a physician (or other qualified provider) other than the physician performing aneurysm, pericarditis, renal failure, acute myocardial infarction, chest trauma, the procedure. Note that these codes include any ECG monitoring or a malignancy. Treatment involves the emergent removal of the fluid. (93040–93042) the physician may perform. Local anesthesia is included in these services. For radiology supervision and interpretation, see 76930. Medicare Edits Fac RVU Non-Fac RVU FUD Status MUE ICD-10-CM Diagnostic Codes 33010 3.49 3.49 0 A 1(2) A18.84 Tuberculosis of heart 33011 3.52 3.52 0 A 1(3) A39.53 Meningococcal pericarditis A43.8 Other forms of nocardiosis A52.06 Other syphilitic heart involvement Modifiers Medicare Reference A54.83 Gonococcal heart infection 33010 51 N/A N/A N/A None A93.8 Other specified arthropod-borne viral fevers 33011 51 N/A N/A 80* B33.23 Viral pericarditis * with documentation C45.2 Mesothelioma of pericardium D15.1 Benign neoplasm of heart D48.7 Neoplasm of uncertain behavior of other specified sites I01.0 Acute rheumatic pericarditis CPT © 2015 American Medical Association. All Rights Reserved. © 2015 Optum360, LLC Coding Companion Arteries and Veins — 185 K51.512 Left sided colitis with intestinal obstruction 45340 K51.812 Other ulcerative colitis with intestinal obstruction K51.912 Ulcerative colitis, unspecified with intestinal obstruction 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation K56.5 Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) K56.60 Unspecified intestinal obstruction K56.69 Other intestinal obstruction K91.3 Postprocedural intestinal obstruction Q42.0 Congenital absence, atresia and stenosis of rectum with fistula Q42.1 Congenital absence, atresia and stenosis of rectum without fistula Q42.2 Congenital absence, atresia and stenosis of anus with fistula Q42.3 Congenital absence, atresia and stenosis of anus without fistula Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine Q42.9 Congenital absence, atresia and stenosis of large intestine, part unspecified HCPCS Equivalent Codes N/A Terms To Know atresia. Congenital closure or absence of a tubular organ or an opening to the body surface. Explanation balloon catheter. Any catheter equipped with an inflatable balloon at the The physician performs flexible sigmoidoscopy and dilates strictures by balloon end to hold it in place in a body cavity or to be used for dilation of a vessel catheter. The physician inserts the sigmoidoscope into the anus and advances lumen. the scope through the rectum and into the sigmoid colon. The lumen of the complication. Condition arising after the beginning of observation and sigmoid colon and rectum are visualized. Areas of stenosis are identified and treatment that modifies the course of the patient's illness or the medical care a balloon catheter is passed to the point of constriction and a little beyond. required, or an undesired result or misadventure in medical care. The balloon is inflated to the appropriate diameter and gradually withdrawn through the stenosed area, stretching the walls of the bowel at the strictured congenital. Present at birth, occurring through heredity or an influence during area. The scope is withdrawn at the completion of the procedure. gestation up to the moment of birth. Coding Tips dilation. Artificial increase in the diameter of an opening or lumen made by medication or by instrumentation. Moderate (conscious) sedation performed with 45340 is considered to be an integral part of the procedure and is not reported separately. However, intestinal or peritoneal adhesions with obstruction. Abnormal fibrous anesthesia services (00100–01999) may be billed separately when performed band growths joining separate tissues in the peritoneum or intestine, causing by a physician (or other qualified provider) other than the physician
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