I work for an insurance company and I’m seeing this code submitted on claims for males. Any thoughts as to why? Poor coding and misuse? Used for conditions other than postmenopausal like testosterone depletion? Let me know your thoughts why this would be justified for males.
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Tag Archives: Replacement
Mic-Key Button Replacement
So my provider completed the following procedure and I am not sure the proper code:
G12.21 ALS (amyotrophic lateral sclerosis) (HCC) (primary encounter diagnosis) – Under sterile conditions the Mic-Key button was replaced today without difficulty. 20F 3cm tube inserted and balloon inflated with 5 mL sterile water (recommended 5mL, max 10 mL). 60mL sterile water then infused through the G-tube site without difficulty, and without subsequent leakage from around tube site. Tube with more play, no longer retracted into the stomach wall with the pressure of balloon. Much more comfortable per patient
The current code I am looking at is 43760 — change of gastronomy tube, per-cutaneous w/o imaging or endoscopic guidance but when I read the detailed description it seems more complicated than what my provider did in office.
Further description indicates:
The physician changes a gastrostomy tube via per-cutaneous approach. No imaging or endoscopic guidance is utilized. If the old gastrostomy tube has been placed endoscopically, the physician must remove it by snaring and pulling it out through the mouth. A new tube is placed subcutaneously through the abdominal wall via the existing tract. A small incision is made through the skin and fascia. A large bore needle with suture attached is passed through the incision into the lumen of the stomach. The needle is snared and the needle and suture are removed via the mouth. The gastrostomy tube is connected to the suture and passed through the mouth into the stomach and out the abdominal wall. The gastrostomy tube is sutured to the skin.
Thank you!!
Total Knee Replacement in ASC
I have a company that is considering doing total knee replacements in an ASC. Does anyone have any experience with billing/coding for this? I believe it would be billed with 27447 as CPT Code and either L8699 for the implant or C1776. What would be reimbursement for a private payor? The only thing I can find is that it should be performed as an inpatient procedure. Please let me know. Thank you. Kim
PEG tube replacement
Hello,
Can anybody give CPT code for PEG tube replacement done endoscopically?
Knee Replacement HELP!!!
CODING QUESTION: Please HELP!!!! I purchased a general surgery study guide book that does not provide the rationale nor the answers. And I’m trying to conquer my fears of long long case studies. I’m not sure if it’s 27746 or 27742. Can someone please help? I don’t see any exchanges so I know it can’t be a revision and the components are unilateral at least I believe so
Diagnosis: Advanced Osteoarthritis
Operation: Left knee replacement using Zimmerman ultracongruent component, loaded antibiotic cement
Description of Procedures: The patient was brought to the operating room after satisfactory induction of Spinal anesthesia. A standard anterior incision was made followed by a median parapatellar approach to the knee. The soft tissues were released from around the medial aspect of the tibia and both the anterior and posterior cruciate ligaments were respected from the notch. An intramedullary alignment guide was used to direct the distal femoral cut at 6 degrees of valgus, was taken off due to the disparity between the medial and lateral femoral condyles in this projection. Distal femoral cut was made. Retractors were positioned around the proximal tibial cut. The minimal 2mm was taken off of the very most worn posterolateral portion of the lateral tibial plateau. The extension gap was checked. It appeared the knee would take a 10mm polyethylene.
Attention was returned to the distal femur. It sized to a size 5. Rotation was adjusted using the posterior referencing guide at 3 degrees of external rotation, it was cross-referenced with Whitesides line, which it matched and the epicondylar axis. The size 5 cutting block was attached and the distal cut on the femur were made. The proximal tibia sized to a size E. Rotation was adjusted , so the middle portion was along the medial 1/3 of the patellar tendon. The proximal tibia was then reamed and broached to accept a size E tibial component. The patella tracked well. A lateral release was not needed. The patella was not resurfaced, but the peripheral osteophytes from around the edges were removed. The trial components were removed. The bony surfaces were prepared with the pulsating lavage. One batch of high viscosity cement with antibiotic was mixed at the appropriate consistency. The tibia was cemented, followed by the femoral component. Extraneous cement was removed from around the edges and the trial 10 mm polyethylene was put onto the tibial tray. The leg was brought into full extension to allow the cement to harden. While the cement was hardening, the bone surfaces were not covered by implant, were covered by bone wax. The cement required just over 13 minutes to harden, after which the tourniquet was released. Tourniquet time was under 50 minutes. No unusual bleeding was encountered. The posterior aspect of the knee was carefully inspected to make certain there were no remnants of debris, bone cement, etc. The final deep irrigation and inspection was carried out and then the real 10 mm ultracongruent polyethylene was put onto the tibial tray. The deep tissues were closed with interrupted figure-of-eight #1 Vicryl. The subcutaneous tissues were closed with 2-0 Vicryl & skin was closed with skin staples. Bulky dressing was applied.
Surgical drain replacement breast
Patient had a previous partial mastectomy in which a drain was placed. At the post-op visit, it was
clear that the drain was not working adequately. Patient was taken back to the hospital for
replacement of surgical drain in her breast. Patient is Medicare. What CPT code do we use?
thanks!
clear that the drain was not working adequately. Patient was taken back to the hospital for
replacement of surgical drain in her breast. Patient is Medicare. What CPT code do we use?
thanks!
Medicaid Replacement Plan billing question
I’m pretty new and billing/coding and need clarification when billing for Medicaid Replacement Plans.
I work at an urgent care center.
(Aetna Better Health of Missouri)
1. Can we bill the Medicaid replacement plan for labs that we send out like 87491 and 87591 or do the Labs need to bill the plans directly?
2. We have a global rate and also fee for service on our contract. I’ve coded for the S9083, 87491/87591, and have been paid for all services. Is this a payment error and should I be expecting at take back on this claim….
Any clarification would be great.
8/8/16 revision of total hip and knee replacement lcd l33456
Can anyone help me?
I was under the impression that the changes to CMS LCD L33456 for total joint replacement was the addition on ICD-10 codes.
I must be missing something because I have a number of total hips and total knees that are denying for medical necessity due to the revised LCD and cannot seem to get a resolve.
Our carrier, Palmetto GBA states there is a required secondary diagnosis missing but i can only find that information associated with the revisions.
I was under the impression that the changes to CMS LCD L33456 for total joint replacement was the addition on ICD-10 codes.
I must be missing something because I have a number of total hips and total knees that are denying for medical necessity due to the revised LCD and cannot seem to get a resolve.
Our carrier, Palmetto GBA states there is a required secondary diagnosis missing but i can only find that information associated with the revisions.
8/8/16 revision of total hip and knee replacement lcd l33456
Can anyone help me?
I was under the impression that the changes to CMS LCD L33456 for total joint replacement was the addition on ICD-10 codes.
I must be missing something because I have a number of total hips and total knees that are denying for medical necessity due to the revised LCD and cannot seem to get a resolve.
Our carrier, Palmetto GBA states there is a required secondary diagnosis missing but i can only find that information associated with the revisions.
I was under the impression that the changes to CMS LCD L33456 for total joint replacement was the addition on ICD-10 codes.
I must be missing something because I have a number of total hips and total knees that are denying for medical necessity due to the revised LCD and cannot seem to get a resolve.
Our carrier, Palmetto GBA states there is a required secondary diagnosis missing but i can only find that information associated with the revisions.
2016 Replacement Codes for G0431 and G0434
Current coding for testing for drugs of abuse relies on a structure of “screening” (known as “presumptive” testing) followed by “confirmation” to confirm the results of the screening tests and quantitative or “definitive” testing that identifies the specific drug and quantity in the patient.
Presumptive Testing
A test used to detect the presence of a drug in a urine sample. The test is performed by a provider with Certification of Waiver or a Medical Test Site Accredited License. Findings are reported qualitatively as either positive or negative.
Definitive Testing
Definitive tests are performed in a laboratory or by a provider with Certificate of Registration, Compliance of Accreditation or Medical Test Site Categorized License or Accredited License. The tests are able to quantify the amount of drug or metabolite present in the urine sample. definitive tests can be used to confirm the presence of a specific drug identified by a screening test and can identify drugs that cannot be isolated by currently available presumptive testing. Results are reported as specific levels of substances detected in the urine sample.
Effective for the dates of services from January 01, 2016 CMS implemented the following changes for drug testing;
1. Deleted the HCPCS codes G0431, G0434 and G6030 through G6058
2. Continue to not recognize the AMA CPT codes 80300 – 80377
3. For presumptive testing, created three G codes:
G0477 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service
G0478 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service
G0479 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service
4. For definitive drug testing, created four tiered G codes:
G0480 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed
G0481 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed
G0482 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed
G0483 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed
Guidelines to report Presumptive Testing;
Presumptive codes G0477 – G0479 is eligible for reimbursement when testing is performed in an office, laboratory or facility setting. These codes are not eligible for reimbursement for chemical dependency facilities. Reimbursement for procedure codes G0477 – G0479 is limited to one unit per day. Only one of the three codes may be billed per day.
Guidelines to report Definitive Testing;
The definitive tests must be both more sensitive and specific than the initial screen. Reimbursement for procedure codes G0480 – G0483 is limited to one unit per day. The unit used to determine the appropriate code to bill is “drug class.” The number of drug classes tested determines the appropriate code to use. Each drug class may only be used once per day. Only one of the four codes may be billed per day.
Modifiers
Modifiers 59, XE, XP, XS, XU and 91 should not be reported with procedure codes G0477-G0479 and G0480-G0483 to bypass the edits.
Reference:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2016-CLFS-Codes-Final-Determinations.pdf
Presumptive Testing
A test used to detect the presence of a drug in a urine sample. The test is performed by a provider with Certification of Waiver or a Medical Test Site Accredited License. Findings are reported qualitatively as either positive or negative.
Definitive Testing
Definitive tests are performed in a laboratory or by a provider with Certificate of Registration, Compliance of Accreditation or Medical Test Site Categorized License or Accredited License. The tests are able to quantify the amount of drug or metabolite present in the urine sample. definitive tests can be used to confirm the presence of a specific drug identified by a screening test and can identify drugs that cannot be isolated by currently available presumptive testing. Results are reported as specific levels of substances detected in the urine sample.
Effective for the dates of services from January 01, 2016 CMS implemented the following changes for drug testing;
1. Deleted the HCPCS codes G0431, G0434 and G6030 through G6058
2. Continue to not recognize the AMA CPT codes 80300 – 80377
3. For presumptive testing, created three G codes:
G0477 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service
G0478 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service
G0479 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service
4. For definitive drug testing, created four tiered G codes:
G0480 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed
G0481 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed
G0482 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed
G0483 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed
Guidelines to report Presumptive Testing;
Presumptive codes G0477 – G0479 is eligible for reimbursement when testing is performed in an office, laboratory or facility setting. These codes are not eligible for reimbursement for chemical dependency facilities. Reimbursement for procedure codes G0477 – G0479 is limited to one unit per day. Only one of the three codes may be billed per day.
Guidelines to report Definitive Testing;
The definitive tests must be both more sensitive and specific than the initial screen. Reimbursement for procedure codes G0480 – G0483 is limited to one unit per day. The unit used to determine the appropriate code to bill is “drug class.” The number of drug classes tested determines the appropriate code to use. Each drug class may only be used once per day. Only one of the four codes may be billed per day.
Modifiers
Modifiers 59, XE, XP, XS, XU and 91 should not be reported with procedure codes G0477-G0479 and G0480-G0483 to bypass the edits.
Reference:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2016-CLFS-Codes-Final-Determinations.pdf