We use an EMR for billing and the insurance companies are requiring all addressed diagnosis be reported on the 1500 claim. The problem is our EMR only allows 4 icd10 codes per CPT code. If patient is only in for one E/M-we are in a family practice office-what to do? Can anyone help me with this? Do you use "dummy" CPT codes? Thank you!
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Tag Archives: Complex
Help with complex hernia repair
Hi all,
I wanted to know if anyone can review this op report and give me your thoughts on it. My doctor wants to bill an unlisted code for the hernia repair but I believe CPT codes 49566 and 49568 support the documentation. I think I’m getting thrown off because of where the hernia occurred (thoracoabdominal area). I have attached the op report with all identifying info blocked out as well as pasted the report below.
____________
PREOPERATIVE DIAGNOSIS:
1. Left thoracoabdominal incisional hernia.
2. Status post latissimus dorsi flap to the left thorax.
3. Status post remote left thoracoabdominal gunshot wound.
POSTOPERATIVE DIAGNOSIS:
1. Left thoracoabdominal incisional hernia.
2. Status post latissimus dorsi flap to the left thorax.
3. Status post remote left thoracoabdominal gunshot wound.
PROCEDURE:
1. Repair of complex left thoracoabdominal incisional hernia,
recurrent, with mesh.
2. Extensive lysis of adhesions.
INDICATIONS FOR PROCEDURE: This patient is a patient who suffered a self-inflicted shotgun wound to the left thoracoabdominal region several years ago. Had a very complicated history but ultimately recovered with a significant symptomatic incisional and wound-related hernia in the left thorax, in the area of the stomach and left chest wall. The patient underwent attempt at repair a year ago, at which time had a latissimus dorsi flap placed for coverage, but the hernia was unable to be successfully repaired due to inability to place a prosthetic mesh.
PROCEDURE:
Patient was brought to the operating room and positioned supine on the operating room table, intubated, and then positioned with the left side up for a left-sided incisional hernia repair in the left thoracoabdominal region, essentially from the nipple to the 12th rib, from the mid clavicle to the anterior axillary line.
Once the patient was properly positioned, all pressure points were protected, the area was prepped with Chlorhexidine solution and sterilely draped, with the additional use of a Biodrape. We began with a curvilinear incision, on the medial aspect of the flap, entering the area of the hernia and at this point we encountered the colon and small bowel. A very tedious lysis of adhesions was then performed. Enterolysis required approximately 2 1/2 hours, in order to mobilize the colon and small bowel, in order to gain a plane for mesh placement. There is no way to repair this hernia without a mesh. The area was clean, and there were no enterotomies or contamination. We chose a Ventralight mesh and cut it to size, approximately 16 cm x 8 cm and we began sewing it into place as an underlay with interrupted 0 Ethibond suture. The mesh lay in good position, was nice and tight. We irrigated with antibiotic solution, and confirmed hemostasis. Ultimately, we closed the wound, bringing the flap back into place, tacking it down and sewing the tissues in layers with Vicryl suture, and skin staples. Patient tolerated the procedure well.
Military Industrial Complex Versus Medical Industrial Complex
Is the military industrial complex 100% evil? Oh, heavens no, however it does need to be kept in check. Obviously, during war times there will be more military spending by any given nation, a time when the country’s treasury is more focused on winning a way, or survival of the civilization. This of course means that those companies that make weaponry stand to make a hefty sum on making those weapons of war. This concerns many and rightfully so.
You see, if those companies lobby politicians to promote certain policies that could lead to a war or cause a lengthened conflict, then they stand to make billions in revenue. The concept of Military Industrial Complex is merely a take-off of Adam Smith’s warnings. Unfortunately, when companies make money through the slaughtering of one’s own race, yes that would be the darkest side of the reality.
Still, on the positive side, a nation that spends healthily on military defense measures is far less likely to be attacked, as their opponents realize the reciprocal will be swift and devastating. An enemy knowing of the economic strength and tight relationship of the industrial military complex with the leadership of the nation, would be wise to think twice about provoking them to serve their political will.
So, those are some pros and cons to the Industrial Military Complex, but what about other such cozy relationships between industry and government? Well, today, we see the Medical Industrial Complex, and oh my gosh it looks like very few in Big Pharma are taking the 50-60% hit on their stock like all the other industries, so what do we do?
Well, it appears the politicians are allotting them these companies, that industry, and the broken healthcare system even more, a $ 690 Billion down payment on a 10-year plan via President Obama’s? So, what’s the difference between the Industrial Medical and Industrial Military Complexes? From Adam Smith’s famous treaties not much in principle or philosophy.
In fact, I just bet Adam Smith would, if he had to choose, side with the Military Industrial Complex over the other, because he knew that government’s first and foremost responsibility was to protect the American People from enemies foreign and domestic, while the purpose of the Medical Industrial Complex is just to make maximum profits at the expense of the people and our government’s treasury. Think on this.
Lance Winslow – Lance Winslow’s Bio. If you have innovative thoughts and unique perspectives, come think with Lance; http://www.WorldThinkTank.net/.
complex repair or intermediate repair
Hi
Pt presented with 15 cm laceration on leg and it was repaired with dermabond at skin outer most layer, with vicryl suture at subcutaneous level and vicryl at deeper layer i gave 12035. Does it goes to complex repair.
Complex fenestrated graft (ELG) 34846?
Hello,
I am new to ELG’s I need help coding the following report:
I am new to ELG’s I need help coding the following report:
INDICATIONS FOR THE PROCEDURE: The patient is a 78-year-old male with
an abdominal aortic aneurysm. He has a complex aneurysm with a posterior penetrating
aortic ulcer, proximal juxta-renal saccualr AAA, and a inra-renal fusiform AAA. Due to
the multilevel anatomy of the aortic pathology we proceeded with a fenestrated endoluminal
graft repair. The patient was taken to the operating room on an elective basis.
PROCEDURE IN DETAIL: The patient was taken to the operating room,
placed supine on the operating table. General endotracheal anesthesia
was achieved. All invasive monitoring lines were placed by the
anesthesiologist and the OR staff. The chest, abdomen, pelvis, and
bilateral lower extremities were prepped and draped in standard surgical
fashion. Percutaneous retrograde bilateral common femoral
arterial access was obtained with the micropuncture kit. Bilateral iliofemoral
angiograms were performed to verify correct common femoral artery access.
Retrograde access of both common femoral arteries was obtained with two
6-French sheaths. A 20-French Cook sheath was placed in the left
common femoral artery. The tip of this 20-French sheath was above the
aortoiliac bifurcation. Over an Amplatz wire on the right sheath, the
Cook Zenith fenestrated proximal component size 28 x 94 was
advanced in the proper orientation and positioned with the fenestrations
at the level of the renal arteries. An abdominal aortogram was
performed with repeat magnification view to identify both right and left
renal arteries. The proximal fenestrated component was positioned with
the right renal fenestration at the level of the right renal artery. This
proximal fenestrated component was partially deployed. Multiple wire
and catheter exchanges were used to introduce a wire followed by a 6-
French Ansel sheath and an iCAST stent into each renal artery. Mild
manipulation and adjustment of the position of the proximal component
was performed during the cannulation and instrumentation of both renal
arteries. With the 3 devices in each renal artery, the proximal
component was completely deployed. The proximal fenestrated aortic
device was balloon angioplastied with a 32 mm Coda balloon. The left renal
artery iCAST stent size 5×22 mm was then deployed after which the
proximal aortic end was flared using a 10 mm balloon. The same procedure
was performed on the right side with deployment of the right iCAST renal
artery stent size 6×22 mm with balloon angioplasty flaring of its proximal end in the
abdominal aorta. The delivery device of the proximal component was
then withdrawn. The Zenith fenestrated endograft distal bifurcted device was then
advanced over the left femoral wire and positioned with the proper
overlap with the proximal component and sheath then deployed releasing
the contralateral limb. The contralateral limb was cannulated with a
Glidewire. The position of the contralateral wire and the contralateral
limb was verified using a Coda balloon. A retrograde right iliac
angiogram was performed to identify the takeoff of the left internal
iliac artery. The contralateral iliac limb extension, size 13 mm x 74 mm
was advanced and deployed with the proper overlap with the distal
abdominal component with the distal end of the left iliac limb extension
landing immediately proximal to the right internal iliac artery. A
retrograde left iliac angiogram was then performed to identify the
takeoff of the left internal iliac artery. A left iliac limb
extension, size 13 mm x 56 mm was advanced and deployed with the proper
overlap of the ipsilateral limb of the distal abdominal component making
sure to preserve the left internal iliac artery. A 32 mm Coda balloon
was advanced over the left wire and balloon angioplasty of all the
overlapping distal complements performed. 32 mm Coda balloon angioplasty
of both iliac limb extensions was performed. The Pigtail catheter was then
advanced into the proximal abdominal aorta. A completion abdominal
aortic angiogram with iliac runoff was performed. There was excellent
filling of the right and left renal arteries as well as teh SMA. There was no
evidence of any type 1 or 3 endoleaks. The was a delayed type 2 endoleak
of the proximal saccualr juxtra-renal AAA component. A lateral abdominal
angiogram was perfopmred showing good filling of the SMA. All the wires and
sheaths were then withdrawn. The right and left femoral artery access sites were
secured using the pre-deployed Perclose Proglide vessel closure devices.
Excellent hemostasis of the access sites was obtained. The patient tolerated
the procedure well. There was no evidence of any hemodynamic instability or
compromise during the entire procedure. Heparin was administered
intravenously at the beginning of the procedure and reversed with
protamine at the end of the procedure. The patient was extubated in the
operating room. The patient was transported to the recovery room in
stable hemodynamic and respiratory condition.
I believe the CPT code for this procedure is 34846…but would that be all I can code? Seems like there is so much work involved for one single procedure code. Would the extensions qualify for the 34825 and 34826? If someone would be so kind to help me with this report, I would greatly appreciate it.
Thank you
Debridement and Secondary complex closure of wound dehiscence of bilateral breasts
Assistance needed in coding this case for our ASC.
The physician wants to code as 11010 X 2 & 13160 X 2; however, those codes bundle leaving us with just 13160 as the procedure was performed in the same anatomical site.
My question is, would it be appropriate to code 13160 and 19340 LT for the extra work that went into the left side with the implant being removed, cleaned and replaced?
Pre/Post Op Dx: Bilateral incisional dehiscence of breast reconstruction, status post bilateral mastectomy and immediate reconstruction.
Procedures Performed:
1. Debridement of bilateral breast
2. Secondary complex closure of wound dehiscence of bilateral breast
Indications and Findings:
Patient approximately one month status post bilateral mastectomy and immediate reconstruction using AlloDerm and a permanent implant. Today in followup, she was noted to have dehiscence of her incisions bilaterally. On the right, she remained with viable muscle at the base of her dehiscence; however, on the left, there was exposure of her underlying AlloDerm, and is now returned to the operating room for a secondary closure and attempted salvage.
On the right, the patient was noted to have incisional dehiscence; however, the pectoralis muscle remained viable at the base of the wound. There was no evidence of purulence. On the left, there was exposure of the underlying AlloDerm covering the implant. However, again, there was no evidence of purulence or significant infection. On the left, the wound was initially profusely irrigated with a Pulsavac irrigation system. The implant was then removed, and the entire wound again thoroughly irrigated, and the implant was soaked in Betadine for approximately 25 minutes. The implant was replaced and the wound secondarily approximated as described below.
Description: After anesthesia, the left breast wound was then cultured following which the anterior chest wall was prepped and draped in the usual sterile fashion. Nonviable tissue along the margins of both incisions were sharply debrided. Both wounds were then irrigated with the Pulsavac irrigation system using a betadine saline solution. On the right, the patient was noted to have viable pectoralis muscle at the base of the area of dehiscence; however, on the left, there was exposure of the acellular dermal matrix. The matrix was transected at the area of dehiscence and the implant removed. Again, there was noted to be no evidence of any purulence whatsoever within the pocket. The implant was completely submerged in a betadine solution following which the pocket on the left was again irrigated with a Pulsavac irrigation system. The entire operative field was then broken down and reprepped and draped in the usual sterile fashion. The pocket on the left was then again irrigated with 3 liters of a betadine/saline solution following which the implant was replaced within the pocket. The dehiscence was then approximated using interrupted sutures of 3-0 Vicryl to approximate the acellular dermal matrix in deep subcutaneous tissues. The wound was again irrigated with the Pulsavac irrigation system and the skin approximated using interrupted horizontal mattress sutures of 3-0 Prolene. On the right, the wound was reapproximated using interrupted horizontal mattress sutures of 2-0 Prolene. A sterile dressing consisting of xeroform gauze and Tegaderm was applied following which the patient was taken to the step-down unit in stable condition. All counts were correct. There were no complications.:confused::confused:
Complex Chronic Care Management Services 99487 +99489 (part 2 of 2)
Complex Chronic Care Management Services 99487 +99489
(Part 2 of 2)
December 21, 2016
As we discussed in the article for chronic care management services (code 99490) these patients that utilize these services are those that are generally chronically ill who have continuous and/or ongoing episodic “chronic medical diagnoses. The majority of these patients are receiving these services within an assisted living facility, some still reside at home, and others are in a full-service nursing care center.
Complex Chronic Care Management is not reported by location, but are provided in coordination with other care providers and at times, performed by clinical staff that is not necessarily an MD or DO. It is not uncommon to see the clinical staff document, develop, implement, and revise care plans for these complex chronically ill patients. However, this takes place under the direction of the physician and/or other qualified health care professionals such as a Physician Assistant, or Nurse Practitioner.
CPT in 2017 denotes the codes 99487 with add-on code 99489 for the reporting of Complex Chronic Care Management codes. (note: Code 99488 has been deleted) The acronym “CCCC” which stands for complex chronic care coordination – is often noted in the clinical documentation to report these services. Patients needing complex care coordination often have many providers involved with their care, which can include physical therapy, psychiatric and behavioral services, social and home care services, in addition to on-going internal medicine, specialty services for cardiology, orthopedics, neurology, urology, etc.
The 99487 and the add on code 99489 that we utilize from CPT is coded similar to those codes such as critical care services and is a time-based service in addition to other qualifiers that must be met.
CPT created these codes to assist physicians in billing for time spent coordinating the many different services and medical specialties needed to effectively provide are for these complex patients’ and their medical condition(s), psychosocial needs and normal every-day activities.
When billing for complex chronic care management services CPT has outlined very specific guidelines. These guidelines within CPT state that complex chronic care management services are provided during a “calendar month” timeframe and include criteria to be met
· Establishment OR substantial revision of a comprehensive care plan that includes:
o Medical, Functional and/or Psychosocial problems requiring medical decision making of moderate or high complexity;
o Includes clinical staff care management services for at least 60 minutes under the direction of the physician
· CPT also states that these patients are treated with three or more prescription medications, and receiving other types of therapeutic interventions such as PT or OT.
The usage of these codes may NOT be reported if the care plan is “unchanged” or requires only a “minimal” change (such as a medication change or an adjustment to a treatment modality is ordered).
In addition the patients that require complex chronic care management services have multiple illnesses, multiple medication use, and the inability to perform activities of daily living, requirements for a care-giver and/or repeat admissions to an inpatient facility or emergency department. Normally they will have two or more chronic continuous or episodic health conditions that are expected to last at least 12 months OR until the death of the patient, and the patient is at risk of death, acute exacerbation/decompensation or functional decline. These patients are truly at risk for mortality/morbidity issues.
CPT has given us a handy table to code from for this time based service:
|
Total Duration of Staff Care Management Services
|
Complex Chronic Care Management
|
|
Less than 60 minutes
|
Not reported separately (Use standard E&M)
|
|
60 to 89 minutes
(1 hour – 1 hour 29 minutes)
|
99487
|
|
90 – 119 minutes
(1 hour 30 minutes – 1 hour 59 minutes
|
99487 and 99489 x 1
|
|
120 minutes or more
(2 hours or more)
|
99487 and 99489 x 2 and 99489 for each additional 30 minutes
|
Since CPT deleted code 99488 if the physician has a face to face visit with the patient during this same timeframe within the month, the coder should bill with the appropriate E/M code. The physician or provider also needs to include a “separately identifiable’ way for the coder to see the documentation of this care management so this time-based service can be accurately coded and viewed to ensure that the clinical reporting is valid and meets all criteria in addition to the notation of time. CPT has also included the caveat “if the physician personally performs the clinical staff activities, his/her time may be counted toward the required clinical staff time to meet the elements of the code”.
CMS is proposing for 2017 the following RVU allocation on these two codes as shown in the table below. With CMS including RVU’s on these codes, it is much more incentivizing for physicians to perform, document and bill for the complex chronic care management services.
CMS Proposed Work Values for fy2017
|
HCPCS
|
Descriptor
|
Current work RVU
|
RUC work RVU
|
CMS work RVU
|
|
99487
|
Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.;
|
0.00
|
–
|
1.00
|
|
HCPCS
|
Descriptor
|
Current work RVU
|
RUC work RVU
|
CMS work RVU
|
|
99489
|
Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
|
0.00
|
–
|
0.50
|
As billers and coders, it is our job to code and bill appropriately for the care being provided. Code 99487 and the add on code 99489 were implemented to incentivize providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions. Unfortunately, as a biller/coder, it may be hard to “find” this care documentation within the chart. In addition to charting the “time” the diagnosis for the two (or more) chronic conditions must be documented and clearly connected as medically necessary for this oversight care. The medical necessity will be borne out with clear documentation of the provider and the morbidity/mortality of the complex diagnoses being managed.
If there is a question regarding the time spent, or problems being cared for communication with the provider is vital. You can always help your provider get you the appropriate documentation by creating a “clinical documentation checklist” that includes the pertinent information that you need, or have this information readily available in the electronic medical records or health care record. The most helpful clinical documentation includes:
· A clear description of the condition (diagnosis)
· New pertinent clinical findings or outcomes
· New or substantially changed diagnostic and/or therapeutic procedures and services
· New or substantially changed medications/medication listing
· Changes in severity of patient condition
· Clear documentation for the “Month” being code for, and a clear documented record of time spent performing the above.
As the coder/biller, it is your help and expertise, coordinated with the physician and clinical providers, to pull in all the “pieces” which will ensure the utilization of the Complex Chronic Care Management codes of 99487 and 99489 make a difference in the physician practice revenue stream and enhance the patients’ overall care.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.