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Post-op Diagnosis: SAME
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CPT Code: Procedure: DIAGNOSTIC EXCISION LEFT BREAST MASS
*PR EXCISE BREAST CYST
*
ICD-10 : Post-Op Diagnosis Codes:
* Breast mass in female [N63.0]
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Specimens:
ID Type Source Tests Collected by Time
A : palpable mass left breast Breast Breast, Left SURGICAL PATHOLOGY TISSUE EXAM
*
Findings: dense inframammary ridge bilaterally, more pronounced left lower inner parasternal breast margin with ill-defined mass effect. A curved incision was made more centrally with a thick flap created to the area of interest which is generously excised using Harmonic Focus to avoid cautery with her pacemaker in place. At conclusion there is a deliberate flattening of the area without marked contour loss and incision is closed in layers. I did not place a clip.
Indications: She has a prominent inframammary ridge, more so on the left with a slight swelling in the left lower inner quadrant adjacent to the sternum. Imaging discloses no pathology. I performed a needle biopsy and that was nondescript tissue and I would have expected fat necrosis. As an alternative to continued monitoring, she and I decided to pursue a diagnostic excision both to remove the mass but also to assure absence of a proliferative disorder.
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Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. The left breast is prepped with chlorhexidine and draped after 3 minutes. A curved incision is made about 3 fingerbreadths from the lower inner quadrant breast margin, scalpel enters the subcutaneous adipose tissue and I now used Harmonic Focus with a thick 6 mm flap dissected to the medial most margin, and then circumferentially until amputated. I take a small volume more inferiorly to result in a smooth transition and deliberate flattening (the mound has been removed). I used 4-0 Vicryl suture and create a lateral subcutaneous flap and attached superficial aspect of this carried medially to the underside of the medialmost flap. A few more simple interrupted subcutaneous sutures were placed and then the skin closed with subcuticular technique. A Steri-Strip was used as a dressing, she tolerated a Steri-Strip before but otherwise is intolerant of other adhesives. She is now awakened and extubated, transported to PACU.
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Visit has a detailed history and expanded pf exam, and I am thinking a Moderate MDM for a 99214.
My questions are regarding the three elements of MDM.
This is the Impression and Plan Summary:
PAIN IN RIGHT ARM – New.
Orders: US: extremity – right – non vascular.
BICEPS TENDON RUPTURE – New. Ultrasound reveals bicep tendon tear Ortho referral made. May use ibuprofen 800mg PO TID otc prn pain. Medication education provided including possible side effects.
Here are my questions:
1) would the pain in right arm dx count as a moderate level in the table of risk as an Undiagnosed new problem with uncertain prognosis? (Also my boss had mentioned that 2 new problems equal Moderate Risk but I can’t find documentation for that)
2) Does the provider get 2 data points? One point for ordering the US for the pain in arm, and one point for reviewing the US for the bicep tendon tear?
I would appreciate any input regarding this to further my knowledge and understanding regarding MDM and this type of scenario.
TIA
KM
So this is an established patient visit
There is a detailed hx and a detailed exam. The area of disagreement is the MDM. The patient has only the one established problem, that is not worsening. There is no data/tests to review. The plan of care is "lifting capacity will be raised to 30 pounds. He should follow up in 3 months time. In the interim he is to continue strengthening."
So to me, this is straightfoward MDM.
Diagnoses: One established problem, not worsening = straightfoward
Amount & complexity of data is minimal/none = straightfoward
Risk – presenting problem could be low, but diagnostic procedures ordered and management options would only be minimal = straightfoward
The physician feels that this visit is definitely not a 99212. He thinks it should be a 99213, even though I explained that the MDM is the overarching criteria in choosing your code level. He told me, these problems have orthopaedic levels of complexity that are not fully appreciated by one without an orthopedic background.
I admit, I am new to ortho coding, so I am looking for your opinions. What would you code this visit as?
The scenario:
Physician office files a claim to Medicaid MMA and after claim is submitted a commercial insurance is discovered that the patient had not reported to either Medicaid or our office. Our office reports the commercial insurance to the MMA and files a claim to the commercial insurance.
In the meantime the MMA pays claims and then the commercial insurance pays claim, now the claim is overpaid.
I have been resubmitting the claim to the MMA as a corrected claim with a copy of the EOB from the commercial insurance. My thought is that the MMA will see the commercial insurance payment and reprocess their claim and ask for a refund of the overpayment.
What is routinely happening is the MMAs are denying as a duplicate when the claim is clearly marked with a submission code 7 with the claim # references.
My other option would be to submit a voided claim but I feel this is not correct as the service was provided so I do not feel the void would be appropriate.
This is a huge problem for our office. Patients routinely do not disclose their commercial insurance as they do not want to pay ANYTHING and think that if they dont disclose they commercial insurance will not be eventually discovered.
How would you handle the overpayments on the claim?
Thanks!
Tina Smith COC, CPC
Thanks!
Stanita
Any advice would be appreciated! Thank you in advance!