CPC Prep Class Lamon Willis, CPCO, CPC-I, COC, CPC - PowerPoint Presentation

1. CPC Prep ClassLamon Willis, CPCO, CPC-I, COC, CPCAHIMA-Approved ICD-10-CM/PCS Trainer

2. DisclaimersCPT® codes are the registered trademarked nomenclature of the American Medical Association (AMA) and are licensed and purchased for use in payment schema, including software systems through that organization.ICD-CM codes are licensed for use by the World Health Organization (WHO), and ICD-PCS codes are developed and offered for use by the Centers for Medicare and Medicaid Services (CMS) within the United States of America.

3. TOP MISSED CODING CONCEPTS

4. Lesion ExcisionsThings to look for in documentation:How is the lesion excised?What type of lesion is it?How large is the excised diameter?What is the depth of the excision?How is the defect closed?Can the closure be coded in addition to the excision?Are there multiple lesions?

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6. Shave LesionsThe sharp removal of an epidermal or dermal lesion that does not require suturing11300-11303Per lesion located on the trunk, arms or legs11305-11308Per lesion located on the scalp, neck, hands, feet, genitalia11310-11313Per lesion located on the face, ears, eyelids, nose, lips, mucous membraneNote the size in your code selection

7. Coding Lesion ExcisionMeasuring and Coding of Lesion RemovalPer CPT - Excision is defined as full thickness removal of a lesion, including margins.Code selection is based on measuring the greatest clinical diameter of the lesion plus the narrowest margins required for complete excision.

8. Lesion MeasurementLargest excised diameter plus marginsLesion measuring 2.0 cm x 1.0 cm with 0.2 cm margins = what?2.0+0.2+0.2 = 2.4 cm? or2.0+1.0+0.2+0.2 = 3.4 cm?

9. Lesion MeasurementExamples of lesion at widest dimension + margin at narrowest width:1.0 cm lesion with 0.5 cm margin left and 0.5 cm margin right = 2.0 cm1.0 cm x 2.0 cm lesion with 1.0 cm margin left and 1.0 cm margin right = 4.0 cm2.5 cm x 0.6 cm lesion with 0.3 cm margin left and 0.3 cm margin right = 3.1 cm

10. Benign or Malignant LesionsCode selection is based on:Diagnosis (Pathology)LocationExcised site with narrow margins

11. Benign Lesions11400-11406Trunk, arms or legs11420-11426Scalp, neck, hands, feet, genitalia11440-11446Face, ears, eyelids, nose, lips, mucous

12. Malignant Lesions11600-11606Trunk, arms or legs11620-11626Scalp, neck, hands, feet, genitalia11640-11646Face, ears, eyelids, nose, lips, mucous

13. Closure with ExcisionsAdjacent tissue transfer or rearrangement excision of lesions are NOT reported separatelySimple closures are NOT reported separately with lesion excisionsIntermediate and Complex closures are reported in addition to the excisionSkin grafts are reported in addition to the excision

14. RepairsSimple (12001-12021)Superficial, epidermis or dermisIntermediate (12031-12057)Layered, deeper layers of sub-q tissueComplex (13100-13160)Scar revision, debridement, undermining

15. Simple RepairUsed when the wound is superficial. Typically involves the epidermis or dermis, or subcutaneous tissues without significant involvement of the deeper structure of the skin.A ONE-layer closure

16. Intermediate RepairIncludes the repair of wounds that in addition to what is described in the Simple Repair, required layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure.Single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes the use of intermediate repair codes.

17. Complex RepairIncludes the repair of wounds requiring more than layered closure, such as scar revision, debridement, extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs or the debridement of complicated lacerations or avulsions.

18. Adjacent Tissue TransferFlaps (14000-14350)Also known as Z-plasty, W-plasty, Rotation FlapMeasured in square cmCode determined based on locationAs described per CPT; excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement.

19. Adjacent Tissue TransferSkin graft necessary to closed secondary defect is considered an additional procedure. The primary defect resulting from the excision and the secondary defect resulting from the flap design to perform the reconstruction are measured together to determine code selection.

20. Flaps and Grafts

21. Flaps and Grafts

22. Flaps and Grafts

23. Flaps and GraftsGrafts (15002-15278)Split Thickness or Full ThicknessAllograft or XenograftSTSG – Split Thickness Skin Grafts (Autograft)In doing an STSG healthy upper layers of the skin are transplanted to the defective areaFTSG – Full Thickness Skin Grafts (Autograft) In doing an FTSG the surgeon obtains a full thickness graft that includes the layers of the skin and blood vessels

24. Flaps and GraftsAllograft (Donor Graft – Skin Substitute)With an Allograft this is from a human donor, typically a cadaverXenograft (Porcine Graft – Skin Substitute)With Xenograft, this typically is the skin of a pig that would be used to close the wound

25. Split Thickness/Full Thickness GraftsCode range for STSG15100-15101 (Truck, arms, and legs)15120-15121 (Face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits)Code range for FTSG15200-15201 (Trunk)15220-15221 (Scalp, arms, and legs)15240-15241 (Forehead, cheeks, chin, mouth, neck axillae, genitalia, hands and feet)15260-15261 (Nose, ears, eyelids, and lips)

26. Skin Substitute GraftsCodes 15271-15278 were added to CPT in 2012 to account for substitute products for skin replacement.The codes cover the body area for coverage, total square centimeter of the wound surface, with add-on codes for additional increase in square centimeter of coverage materials.

27. Skin Substitute GraftsExample: A 345 sq cm skin substitute graft of the right arm and a 95 sq cm substitute graft of the left arm Codes: 15273, 15274 x 4

28. Kyphoplasty and Vertebroplasty

29. Documentation IssuesThings to look for:Is a balloon used to create a cavity? Report kyphoplasty.How many vertebral bodies are involved?What type of imaging guidance is used?

30. Documentation IssuesTerminology changesKyphoplasty now referred to as “percutaneous vertebral augmentation”Codes are found at 22513-22515Codes are for one “1” vertebral body for the body areas listed:ThoracicLumbarCodes are unilateral or bilateralImaging is included

31. Documentation IssuesVertebroplasty codes are 22510-22512These are percutaneous codesThe codes are for one (1) vertebral body for the body areas listed:CervicothoracicLumbosacralCodes are unilateral or bilateralBone biopsy is includedImaging is included

32. Vertebroplasty

33. Kyphoplasty

34. VertebroplastyVertebroplasty is often utilized because:More extensive repair experienceGood pain relief recordRelatively quick procedurePerformed as an outpatient procedureLess costly than kyphoplasty

35. Selective Catheter Placement

36. Documentation IssuesWhich vessel and which order? Use Appendix L of the CPT4 manual.Are other interventions performed (such as angioplasty)?What services are bundled with the procedures?

37. What Is Appendix L?Appendix L is a tree of vascular families intended to help you assign codes for catheterizations performed assuming:Normal anatomyCatheterization started in the aorta

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39. Selective Arterial Cath PlacementCodes 36215-36218 used for thoracic and brachiocephalic arterial systemCodes 36245-36248 used for abdominal, pelvic, and lower extremity Codes 36251-36254 used for renal arteries

40. Example ProcedureA catheter was placed into the abdominal aorta via the right common femoral artery access. Abdominal aortography was performed. These images demonstrated a patent single left renal artery, but the right renal artery was inadequately visualized. The catheter was used to selectively catheterize the right renal artery. Selective right renal angiography was then performed, demonstrating a widely patient right renal artery.

41. Endovascular RevascularizationFor treatment of occlusive disease in lower extremitiesThree territoriesIliacFemoral/PoplitealTibial/Peroneal

42. Endovascular RevascularizationCodes arranged in a hierarchy for each territoryStent placement with atherectomy (highest)AtherectomyStent placementAngioplasty (lowest)

43. Endovascular RevascularizationServices which are bundled in the procedure:Conscious sedationVascular accessCatheter placementTraversing the lesionImaging related to the intervention (previously billed as supervision and interpretation code for specific intervention)Use of embolic protection device (EPD)Imaging for closure device placementClosure of the access site

44. Hernia Repairs

45. Documentation IssuesWhat type of hernia is it?Is it recurrent or initial?Is it incarcerated or strangulated?What is the age of the patient?Is mesh used and can it be reported with the type of hernia repair?

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48. Documentation IssuesA hernia is an abnormal protrusion of the whole or part of a viscus through an opening in the wall or cavity which contains it.Inguinal (groin) Hernia – commonly occurs in males, multiple in type:Dual/Pantaloon/Saddle – both direct and indirect sacsSliding – retroperitoneal organ is part of the sacRichter’s – only part of circumference of the small gut is obstructedMaydl’s – a “W” shaped herniaLittre’s – Meckel’s diverticulumAmyand’s - Appendix

49. Documentation IssuesFemoral HerniaLaugier’s – through lacunar ligamentSerofini’s – occurs behind femoral vesselsTeale’s – in front femoral vesselsCallison-Cloquet – through pectineal fasciaHesselbach’s – occurs lateral to femoral arteryNarath’s – occurs behind femoral artery, in congenital dislocation of hip

50. Documentation IssuesVentral Hernia – any protrusion through the anterior abdominal wall is referred to as a “ventral hernia”Categorized as “spontaneous” or “acquired”Spontaneous – primary defects in abdominal fascia includes:Umbilical and periumbilical herniaEpigastric herniaSpigelian herniaAcquired – incisional hernia and parastomal herniaNOTE: CPT groups ventral, umbilical, Spigelian, or epigastric hernia together in the code set.

51. Example CasePreoperative Diagnosis: Lower left inguinal pain Postoperative Diagnosis: Inguinal hernia Procedure: This 30-year-old patient presented with lower left inguinal pain and on examination was found to have a left inguinal hernia. The decision to perform a left inguinal hernia repair was made. The procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed.

52. Example Case (continued)The structural balloon was placed in the preperitoneal space and insufflated to 10 mm Hg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well-defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well. What is the correct CPT4 and/or modifier code for assignment?

53. Circumcision

54. Documentation IssuesIs a clamp or device used?What is the age of the patient?Is a dorsal penile or ring block performed?

55. CircumcisionWhen coding for circumcision, if a clamp or device is used, report 54150 regardless of age. It includes dorsal penile or ring block. If the block is not performed, append modifier 52 per CPT. If excision without device, code based on age.28 days or less report 54160Older than 28 days report 54161

56. Example CaseNewborn male (10 days old) is scheduled for a circumcision. He is sterilely prepped and draped; a penile nerve block is performed. The circumcision is performed by a ring device. Hemostasis is achieved. Vaseline Gauze dressing applied. Patient tolerated the procedure well.What is the correct CPT4 and modifier code for assignment?

57. Facet Joint Injections

58. Documentation IssuesWhich region of the spine is the procedure performed? How many levels is the procedure performed on? Is it performed bilaterally? What type of imaging guidance is used?

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60. Facet Joint InjectionsCodes selected based on the region of the spine and per level. Imaging and injection of contrast are included. Use modifier 50 for bilateral procedures. Codes 64492 and 64495 can only be reported once per day. If imaging is not used, report 20552-20553.

61. Facet Joint InjectionsCervical or thoracic with fluoroscopic or CT imaging guidance, report: 64490 for the first level 64491 for the second level64492 for the third and any additional levels

62. Facet Joint InjectionsLumbar or sacral with fluoroscopic or CT imaging guidance, report:64493 for the first level 64494 for the second level 64495 for the third and any additional levels

63. Facet Joint InjectionsCervical or thoracic with ultrasound imaging guidance, report0213T for the first level0214T for the second level0215T for the third and any additional levels

64. Facet Joint InjectionsLumbar or sacral with ultrasound imaging guidance, report0216T for the first level0217T for the second level0218T for the third and any additional levels

65. Example CaseThe residual cervical facet joints at the right C3-C4, C4-C5, C5-C6, C6-C7, C7-T1 distributions were identified under the multiplanar fluoroscopic imaging and guidance. A selective cervical facet block at each of the described levels was then completed with a total of 2 cc Marcaine, 0.5%, with 2 mg Kenalog per cc, and 3 mg of Toradol per cc, 1.5 cc intra-articular and 0.5 cc peri-articular, to include appropriate dye dilution of the medial branch innervation at each level. The needles were removed. There was no evidence of hematoma. Sterile Band-Aids were placed, and ice was placed to reduce and postoperative swelling from the needle.What CPT4 code/modifier(s) are assigned?

66. Unlisted Codes

67. Unlisted CodesA service or procedure may be provided that is not listed in this edition of the CPT® codebook. When reporting such a service, the appropriate “Unlisted Procedure” code may be used to indicate the service, identifying it by “Special Report” as discussed in the section below. NOTE: Verify that a code from another section would not be used instead. For example a procedure on the lips, the CPT® code appropriate for the case may be located in the digestive system chapter.

68. Vaccine Administration

69. Documentation IssuesWas counseling performed by a qualified health care provider?If counseling was performed what is the patient’s age?If counseling is performed for a patient up to age 18, how many vaccines administered and how many components does each vaccine include?If counseling is not performed, what is the route and number administered?

70. Vaccine Administration90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 90461 each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) Note: counseling, the age, any route, 90460 is reported for each administration and 90461 is coded for each additional component of the vaccination

71. Vaccine Administration90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Note: it is not age specific, no counseling, the route, is only listed once and is the add-on for each additional vaccine, NO COMPONENT CODING

72. Vaccine Administration90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) 90474 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Note: it is not age specific, no counseling, the route, is only listed once and is the add-on for each additional vaccine, NO COMPONENT CODING

73. Administration Example #1The following vaccine are administered to a 3 year old. The physician performs counseling:90743 Hepatitis B90680 Rotavirus90700 Diphtheria, Tetanus, Pertussis90648 Haemophilus influenza type b90669 Pneumococcal90713 Inactivated Poliovirus

74. Administration Example #2The following vaccine are administered to a 3 year old. The physician DOES NOT perform counseling:90743 Hepatitis B90680 Rotavirus90700 Diphtheria, Tetanus, Pertussis90648 Haemophilius influenza type b90669 Pneumococcal90713 Inactivated Poliovirus

75. Vaccine AdministrationDo not report 99211 if the patient presents for vaccines onlyIf the vaccines are performed on the same date as a well visit, report the preventive E/M with the vaccinesKnow the administration codes used by MedicareG0008 Administration of influenza virus vaccineG0009 Administration of pneumococcal vaccineG0010 Administration of hepatitis B vaccineReport in addition to the vaccine

76. Modifiers

77. Modifier 91Only reported with lab codes (80000 series)Not reported when there is a problem with the specimenNot reported when a code includes multiple specimensExample GTT includes three specimens

78. Modifier 91 ExampleExampleProvider orders 2 arterial blood gases to be performed throughout the day.82803, 82803-91

79. Modifier 76Repeat Procedure or Service by Same Physician or Other Qualified Health Care ProfessionalCan be reported with surgical, radiology and medicine codes

80. Modifier 76Example: Provider orders 2 EKGs to be performed while in the patient is in the office. The physician performs the interpretations.93000, 93000-76

81. ICD-10-CM

82. ICD-10-CMThe official guidelines for ICD-10-CM are in the front of the ICD manual each year. With the change from ICD-9 to ICD-10 there are numerous things coders should be aware of.Be sure you are not only familiar with these guidelines, but know where to find them if necessary during your testing.

83. ICD-10-CMThe official guidelines for ICD-10-CM are in the front of the ICD manual each year. With the change from ICD-9 to ICD-10 there are numerous things coders should be aware of.These guidelines are also referred to and called “conventions.”Be sure you are not only familiar with these guidelines, but know where to find them if necessary during your testing.

84. ICD-10-CM

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88. ICD-10-CM

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90. ICD-10-CM

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92. ICD-10-CM

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97. ICD-10-CM

98. ICD-10-CM

99. ICD-10-CM | BurnsCategories T20-T25 are for current burns and classified by:DepthExtentAgent (X code)Always code to the greatest depth of the burn in a given category/anatomical area. Sequence first the diagnosis that reflects the highest degree of burn when multiple burns are present. Classify burns of the same local site but of different degrees to the subcategory identifying the highest degree of burn.

100. ICD-10-CM | BurnsExamplePatient suffers third degree burns to his right and left thighs (9%) and second degree burns to the abdomen (9%)AnswerT24312A Burn of third degree of left thigh, initial encounterT24311A Burn of third degree of right thigh, initial encounterT2122XA Burn of second degree of abdominal wall, initial encounterT3110 Burns involving 10-19% of body surface with 0% to 9% third degree burns

101. ICD-10-CM | Burns

102. ICD-10-CM | Burns

103. ICD-10-CM | Burns

104. HIPAA

105. HIPPAWhat does this acronym stand for?Health Insurance Portability and Accountability Act of 1996How many parts are there in HIPAA?Five PartsWhich part/title is most important to coders?Title II – Preventing Healthcare Fraud & Abuse, Administration Simplification, and Medical Liability Reform

106. HIPPAAdministration Simplification addresses the need for increased technology for:National standards for electronic health care transactions and code sets National unique identifiers for providers, health plans, and employersPrivacy and Security of health data

107. HIPPAA “covered entity” is defined by HIPAA as:A healthcare provider, such as:DoctorsClinicsPsychologistsDentistsChiropractorsNursing homesPharmacies

108. HIPPAA “covered entity” is defined by HIPAA as:A health plan, to include:Health insurance companiesHMOsCompany health plansGovernment programs that pay for healthcare, such as Medicare, Medicaid, and the military and veterans’ healthcare programs

109. HIPPAA “covered entity” is defined by HIPAA as:A health plan, to include:Workers’ compensation or similar insuranceAutomobile medical payment insuranceCredit-only insuranceCoverage for on-site medical clinicsOther similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits

110. HIPPAA “covered entity” is defined by HIPAA as:A healthcare clearinghouse:This includes entities that process nonstandard health information they receive from another entity into a standard format (such as a standard electronic format or data content), or vice versa

111. HIPPAHIPAA sets standards for electronic healthcare transactions and code sets which include:Health claims and equivalent encounter infoEnrollment and disenrollment in a health planEligibility for a health planHealthcare payment and remittance adviceHealth claim statusReferral certification and authorizationCoordination of benefits

112. HIPPAAny covered entity performing one of those transactions electronically is required to follow the standards set for that transaction, and the standards and codes include:HCPCSCPTICD-10-CMNDC (National Drug Codes)

113. Medical Terminology

114. Medical TerminologyUse your code books to help you with terms you may not rememberBoth ICD and CPT have lots of valuable information in them in this area and also there are illustrations in professional editionsWhen you unsure of a term or abbreviation, look it up in the index of the code books for assistance.

115. Thanks for attending