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  • First off lets begin with what the digestive system includes. IT begins with the lips, includes the mouth, esophagus, small and large intestines and through the anus. It also includes organs related to food digestion such as the liver and pancreas
  • First let’s discuss what is included in the digestive system. The digestive system is responsible for the digestion of food and the elimination of waste. It is made up of a series of hollow organs that are joined from the mouth to the anus. The organs within this system are lined by the mucosa, which contains tiny glands that produce juices to help in the digestion of food. The anatomy of the digestive system begins with the mouth or oral cavity. The lips protect the outer opening, the cheeks form the lateral walls, and the hard and soft palates form the anterior/posterior roof. The floor of the oral cavity is the tongue, which has bony attachments (styloid process, hyoid bone) and is attached to the floor of the mouth by the frenulum. On exiting the mouth, the palatine/lingual tonsils guard the esophagus. The food is swallowed with food forced into the pharynx by the tongue. The tongue blocks the mouth, the soft palate closes off the nose, and the larynx rises so that the epiglottis closes off the trachea. From the esophagus, the food travels into the stomach, the duodenum, the small intestine (jejunum and ileum), the large intestine (cecum, past the appendix, ascending colon, transverse colon, descending colon, spleen to left groin, and then the sigmoid colon), through to the anus. The liver and pancreas are also involved in the digestive process, producing juices that flow through ducts into the upper portion of the small intestine.
  • The ICD-9 diagnosis codes for diseases of the digestive system are located between codes 520 – 579. (Read slide . . . The oral cavity, salivary glands, and jaws can be found between 520 and 529 . . . Etc.)
  • The abdomen is divided into 4 quadrants with 9 regions. The quadrants are: right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant. The nine regions include the right hypochondriac region, epigastric region, left hypochondrias region, right lumbar region, umbilical region, left lumbar region, right iliac region, hypogastric region, and left iliac region.
  • Next let us go over some definitions for the digestive system. Hematemesis: ( vomiting of blood) This would indicate acute upper GI hemorrhage. Melena: (dark colored blood in stool). This would indicate upper of lower Gi hemorrhage. Occult Bleeding: (blood in the stool that can only be seen on lab exam. This would indicate upper or lower GI bleeding. Hematochezia: (bright red blood in stool) This would indicate lower GI bleeding. Distinction between GI hemorrhage and occult blood in stool: GI Hemorrhage may produce either dark, black, tarry, clotted stools (melena) or bright red blood in stool or vomitus. Occult Blood – is invisible to the naked eye and can only be detected through microscopic exam Or guiac test. This indicates that a small amount of bleeding in the GI tract has occurred. Use 792.1 when this occurs and no additional documentation exists to further identify a more serious GI bleed. Of course remember, this must be documented and not gather from the laboratory results itself.
  • Some common causes of GI bleeding are gastric and intestional ulcers, diverticular disease and hemorrhoids. Diverticular hemorrhage doses occur and usually stops spontaneously in most patients. Hemorrhoids can from due to various reasons. ICD provides 5 th digit classifications to indicate whether there is associated hemorrhage in varous digestive system conditions. Make sure when coding the appropriate code is used.
  • Now, lets talk about every coders nightmare! GI hemorrhage. GI hemorrhage is the abnormal escape of blood from the GI tract. ICD ASSUMES that if a GI bleed occurs it is from the GI condition. Codes from the 578 category are NOT to be used when there are specific ICD codes which include the hemorrhage for GI conditions (ulcers, diverticular disease, hemorrhoids, etc). 578 codes are to be used only when the clinician SPCIFICALLY states the bleed is NOT due to the e3xisting GI condition . “ No recent bleed” is not sufficient to use 578. This statement still qualifies for the combo code.
  • Category 530 is Diseases of the Esophagus. It is further divided to include a variety of conditions associated with esophagus such as esophagitits, ulcers, stricture/stenosis, perforation diverticula and others. Esophageal varices are not included here. They are considered a circulatory cnditon and can be found in the 456 category. When coding varices, make sure you know whether the varices are associated with cirrhois of liver or portal HTN. Mandatory double coding is required.
  • If you haven’t heard before you are going to now “ A screening is a screening is a screening”. No matter what if the intent of the procedure was to check out a person who is not exhibiting any signs or symptoms then the DX is the screening code. If an additional condition is found this is added as an additional DX. Now, if the person has had a HX of polyps and they are doing a follow up exam and find polyps then the polyps should be coded first. If the patient is having some type of rectal bleed and internal hemorrhoids are found, the code bleeding internal hemorrhoids, even though there may not be any current bleed from the hemorrhoids.
  • For 2005, many new dental codes were added , as has been mentioned in a previous satellite. I would like to however go over 2 new codes added in the 530 category, Diseases of Esophagus. ICD added 2 new codes in category 530 to identify complications of Esphagostomy. 530.86 Infection of Esophagostomy and 530.87 Mechanical Complications of Esophagostomy. Previously there were coded to 997.4, Digestive system complications. Make sure when using 530.86, you add an additional code to identify the bug causing the infection.
  • Next, we will discuss some of the major changes in CPT Codes for 2005.
  • Next we will discuss some coding guidelines for enscopic biopsies. If biopsy of lesion performed, but not fully excised, the biopsy code is used. If biopsy performed of a lesion and then the remaining portion of the lesion is removed, assign only the excision code. If single/multiple biopsies are performed at the same/different sites of the same organ and none are removed, code only the biopsy once.
  • If biopsy of a lesion is performed and a different lesion is removed, code both the biopsy and the lesion excision. The code for excision cannot state “with” or “without” biopsy. If this is listed, then the biopsy is not coded separately. If multiple lesions are removed using different methods, code separately each method used. Also, use modifier 59 to tell the insurance carrier that the lesions were different and were removed from different areas.
  • There are several techniques generally used when removing lesions – hot biopsy forceps (which includes bipoloar and monopolar cautery), the snare technique, and ablation. However, coming up with the appropriate code based on what has been documented may sometimes be difficult. Coders often find the therapeutic codes (45380, 45381, 45383, 45384, and 45385) confusing because they are only differentiated by the method used to remove a lesion or piece of tissue, and the physician does not always clarify in his the documentation exactly what method was used. Documentation must reflect how each service is performed so it can be determined whether the procedure should be reported with one code for one technique or with multiple codes when multiple techniques were used to remove multiple lesions, in which case the modifier -59 (Distinct procedural service) should be used. Unfortunately, unlike the terminology used other techniques represented in codes 45384 and 45385, the terminology used in the procedure report to indicate when code 45383 should be reported is not as clear cut. The definition of 45383 can be misleading because it only states what techniques the codes should not be used for: hot biopsy forceps (45384), bipolar cautery (45384) and snare (45385). It may not be possible to remove a lesion using one of these techniques, and the lesion may or may not be biopsied before it is ablated using an alternative technique. In other cases it may be impossible or unnecessary to obtain a tissue sample of a lesion or polyp depending upon the location. The ablation of the tissue (tumor, polyp or other lesion) can be performed with many different types of devices (heater probe, bipolar cautery probe, argon laser, etc.) whether or not a sample was obtained with a biopsy forceps before the ablative device is applied. Code 45383 is also frequently used to describe the treatment of benign vascular lesions. When the physician documents the use of hot biopsy forceps to remove a lesion, code 45384 may be used to accurately report the service. Bipolar cautery and monopolar cautery forceps can be used to perform this service. Monopolar cautery forceps create heat in the metal portion of the forceps cup by causing current to flow from the device through the patient to a grounding pad. Bipolar cautery uses current that runs from one portion of the tip of the forceps device to another portion of the forceps device to heat the metal used to cauterize and remove a lesion or polyp. Again, remnants of the lesion after use of a cautery forceps can be cauterized or ablated to completely destroy the intended target. The lesion or tissue removal technique easiest to identify in the operative report is the snare technique, represented by code 45385. The snare technique is most often used to perform a polypectomy during a colonoscopy. When the snare cautery technique is employed, a wire loop is placed around the desired piece of tissue or polyp and is heated to shave off the lesion. Larger lesions may be removed with a single application of the snare or can be removed with several applications of the snare in pieces frequently described as “piecemeal.” Remnants of the lesion after use of a snare can be cauterized or ablated to completely destroy the intended target, but only one technique should be reported to remove a unique polyp or lesion. Snare devices may also be used without electrocautery to “decapitate” small polyps. Most often the colonoscopy report will specify that a “snare technique” was used, but don’t let alternative terminology throw you off. The report may also include the phrases “hot snare,” “monopolar snare,” “cold snare” or “bipolar snare,” all of which should be reported using code 45385. If multiple techniques are used on different lesions or polyps, then the procedure report should specifically describe the technique, the type of lesion and the location of the lesion. The CPT code descriptors for each specific technique include language to indicate that each code should be reported only once even if multiple sites are treated with the same technique. If different techniques are used on separate sites, then the code with the highest value should be listed first on the claim. Other codes should be listed in descending order of value with the modifier -59 to identify that the service was performed at a separate site.
  • The first change we will discuss involves treatment for Gastroesophageal reflux or GERD. The Category III code 0057T has been deleted and converted to the Category I code 43257 to report thermal treatment of the esophagus by endoscopy. During this procedure, an endoscope is inserted through the mouth and into the GI tract to examine the esophagus, stomach, and the first segment of the small intestine. The stomach is inspected for lesions or ulcers. A heat probe is then applied to the sphincter muscle as a treatment for GERD, also known as heartburn. It improves the barrier to regurgitate during or after a meal. This is also called the Stretta procedure.
  • Several new CPT codes were added in 2005 to reflect the rapidly changing field of bariatric surgery. Codes 43644 and 43645 employ laparoscopic techniques to perform gastric restrictive procedures for morbid obesity including Roux-en-Y (roo-en-wi) gastric bypass and small bowel reconstruction to limit absorption. In this procedure, the physician inserts a laparoscope into the abdominal cavity, along with other surgical instruments. The stomach is restricted by placing a band around a small portion of the stomach where it connects to the esophagus. The small bowel is then raised and connected to the newly-formed pouch. Use 43645 is a length of small intestine is removed during the procedure.
  • Parenteral nutrition is often administered to patients and used as a nutritional supplement to daily food intake. In some instances, total parenteral nutrition (TPN), also known as hyperalimentation, is administered to patients in whom gastrointestinal absorption is impaired to a degree incompatible with life. It may also be used for variable periods of time to bolster the nutritional status of severely malnourished patients with medical or surgical conditions. TPN involves percutaneous placement of a central venous catheter into the vena cava or right atrium. A nutritionally adequate hypertonic solution consisting of glucose, amino acids, electrolytes, vitamins and minerals, and sometimes fats is administered daily. An infusion pump is used to facilitate a steady rate of administration. With this technique, the digestive tract is bypassed totally. The catheter carries the liquid directly into the bloodstream, where it is absorbed by the body.
  • For prolonged intravenous infusion, code 90780 and the appropriate number of hours. HCPCS Codes B4164 – B5200 are dedicated for Parenteral Nutrition Solutions and Supplies.
  • Enteral nutrition is used for patients with a functioning intestinal tract but who have disorders of the pharynx, esophagus, or stomach that prevent nutrients from reaching the absorbing surfaces of the small intestine, thus placing the patient at risk of severe malnutrition. Enteral nutrition involves administering non-sterile liquids directly into the gastrointestinal tract through nasogastric, gastrostomy (gas-tros’-ta-me), or jejunostomy (ja-joo-nos’-ta-me) tubes. Feedings may be regulated with an infusion pump and may be administered intermittently or continuously.
  • For tube placement, use CPT code 43752 which requires physician’s skill and fluoroscopic guidance. If the tube was inserted without the skill of a physician, use 90799. HCPCS Codes B4034 – B4157 provide direction for enteral nutrition solutions and supplies.
  • New codes and guidelines have been added at the beginning of the Intestines Excision subsection to clarify the three components of physician work involved in intestinal transplants, which are cadaver or living donor enterectomy, backbench work, and recipient intestinal transplants.
  • CPT Codes 45391 and 45392 have been added to describe the proximal to splenic flexure flexure flexible colonoscopy with endoscopic ultrasound examination. In these procedures, an endoscope is inserted through the anus to examine the large intestine beyond the splenic flexure, which is the first bend of the colon. In 45391, An ultrasound probe is used to allow the doctor to visualize the inside of the colon. In 45392, the probe is used to guide a needle through the endoscope to withdraw fluid or tissue samples for examination and diagnosis.
  • The CPT Code 46947 was established for Hemorrhoidopexy. This code allows a method for coding repair of a hermorrhoidal prolapse utilizing a stapling technique. This procedure is different than other internal hemorrhoidectomy codes, which involve with excision and suture ligation or rubberband ligation of hemorroidal tissue.
  • Medicare uses unique procedural codes to identify claims for services when colonoscopy is performed strictly for colorectal neoplasia screening in patients with average risk (G0121) and high risk (G0105). In these cases, the unique Medicare code is reported instead of the standard CPT colonoscopy code (45378) when there is no need for a therapeutic procedure. Therapeutic procedures include simple biopsies, snare polypectomy, etc. If a therapeutic procedure is performed, then the appropriate CPT code(s) are reported with the ICD-9-CM diagnosis code that reflects the finding that required the therapeutic procedure.
  • Although the code used for Capsule Endoscopies is not new, additional information is needed. In this procedure, GI tract imaging is carried out by a capsule swallowed by the patient, which provides color imaging as it passes through the system. Data is transmitted by the capsule to a data recorder.
  • Next, we must emphasize the importance of modifiers.
  • Even though a procedure has not been completed, it is still billable. The use of appropriate modifiers and sending documentation will ensure reimbursement. Under certain circumstances, a procedure is partially reduced or eliminated at the physician’s discretion. The addition of modifier 52 indicates that the service was reduced. Under a different set of circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a procedure was started but discontinued. This may be reported using modifier 53.
  • If the physician cancels a procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to administration of anesthesia, modifier 73 should be added. Modifier 74 is used when the physician terminates a procedure after administration of anesthesia or after the procedure was started.
  • Diagnostic codes are 145.9 and 149.0
  • Diagnostic codes: 569.3 made the leap the ulcer was of the colon since did a colostomy, 530.81 GERD and 562.11.
  • Dental Services are also part of the digestive system. We are not discussing routine dental care but dental surgery. Part of the next scenario is TMJ. I am attaching the link to the TMJ Association for further reference: http://www. tmj .org/ Insurance considerations: http://www. tmj .org/insurance.asp Diagnostic codes: 524.60 and 520.6
  • Coding

    1. 1. Coding & Billing for the Digestive System Denise Hamilton, RHIA, CCS-P Joletta Maxile, MBA, RHIA, CCP Vickie Nitschke. M. Ed, CRS
    2. 2. What is the digestive system? <ul><li>Starts with lips, mouth, esophagus, small and large intestine through the anus </li></ul><ul><li>Organs related to food digestion (for example, the liver and pancreas) </li></ul>
    3. 3. Digestive System
    4. 4. ICD-9 Codes <ul><li>Oral Cavity, Salivary Glands, and Jaws </li></ul><ul><li>(520 – 529) </li></ul><ul><li>Esophagus, Stomach, and Duodenum </li></ul><ul><li>(530 – 537) </li></ul><ul><li>Appendicitis (540 – 543) </li></ul><ul><li>Hernia of Abdominal Cavity </li></ul><ul><li>(550 – 553) </li></ul>
    5. 5. ICD-9 Codes Continued . . . <ul><li>Noninfectious Enteritis and Colitis </li></ul><ul><li>(555 – 558) </li></ul><ul><li>Other Diseases of Intestines & Peritoneum </li></ul><ul><li>(560 – 569) </li></ul><ul><li>Other Diseases of Digestive System </li></ul><ul><li>(570 – 579) </li></ul>
    6. 6. Abdominal Quadrants
    7. 7. ICD Definitions <ul><li>GI hemorrhage </li></ul><ul><ul><li>Hematemesis </li></ul></ul><ul><ul><li>Melena </li></ul></ul><ul><ul><li>Occult bleeding </li></ul></ul><ul><ul><li>Hematochezia </li></ul></ul>
    8. 8. GI Hemorrhage <ul><li>Common causes </li></ul><ul><ul><li>Gastric and intestinal ulcers </li></ul></ul><ul><ul><li>Diverticular disease </li></ul></ul><ul><ul><li>Hemorrhoids </li></ul></ul><ul><ul><li>(internal/external) </li></ul></ul>
    9. 9. ICD Code 578 <ul><li>GI hemorrhage - Abnormal escape of blood from the GI tract </li></ul><ul><li>NOT used when a combo code exists for previously mentioned GI conditions </li></ul><ul><li>Use ONLY when clinician specifically states bleed not due to GI condition </li></ul>
    10. 10. Diseases of Esophagus <ul><li>ICD Category 530 – Diseases of Esophagus </li></ul><ul><li>Esophagitis </li></ul><ul><li>Ulcers </li></ul><ul><li>Stricture/Stenosis </li></ul><ul><li>Perforation </li></ul><ul><li>Diverticula </li></ul><ul><li>Other </li></ul>
    11. 11. Diagnosis for Screenings <ul><li>“ A screening is a screening </li></ul><ul><li>is a screening” </li></ul><ul><li>Additional condition found </li></ul><ul><li>History of condition and found </li></ul>
    12. 12. Screenings, Etc. <ul><li>DX for screenings </li></ul><ul><ul><li>Use V76.51 </li></ul></ul><ul><ul><li>Add DX codes as secondary </li></ul></ul>
    13. 13. 2005 Changes <ul><li>Many new Dental codes (520-528) </li></ul><ul><li>New codes in category 530 </li></ul><ul><ul><li>530.86 Infection of Esophagostomy </li></ul></ul><ul><ul><li>530.87 Mechanical Complication of Esophagostomy </li></ul></ul>
    14. 14. CPT Coding
    15. 15. Endoscopic Biopsies Coding Guidelines <ul><li>Biopsy performed, but not fully excised, code biopsy only. </li></ul><ul><li>Biopsy performed and remaining portion removed, code excision only. </li></ul><ul><li>Biopsies performed at the same/different sites of the same organ and without removal, code only the biopsy once. </li></ul>
    16. 16. Endoscopy Guidelines Continued . . . <ul><li>Biopsy performed and a different lesion </li></ul><ul><li>is removed, code both the biopsy and the </li></ul><ul><li>lesion excision. </li></ul><ul><li>The code for excision cannot state “with” </li></ul><ul><li>or “without” biopsy. If this is listed, </li></ul><ul><li>then the biopsy is not coded separately. </li></ul><ul><li>If multiple lesions are removed using </li></ul><ul><li>different methods, code each method </li></ul><ul><li>used separately with modifier –59. </li></ul>
    17. 17. Endoscopic Lesion Removal Codes <ul><ul><li>No Documented Technique (45380) </li></ul></ul><ul><ul><li>Other Ablation Technique (45383) </li></ul></ul><ul><ul><li>Hot Biopsy Forceps (45384) </li></ul></ul><ul><ul><ul><li>Monopolar and Bipolar Cautery </li></ul></ul></ul><ul><ul><li>Snare (45385) </li></ul></ul>
    18. 18. Definitions and New Codes
    19. 19. CPT Codes <ul><ul><li>0057T converted to 43257 </li></ul></ul><ul><ul><li>Upper GI endoscopy, including esophagus, stomach and either the duodenum and or jejunum as appropriate; with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of GERD </li></ul></ul><ul><ul><ul><li>Called the Stretta procedure </li></ul></ul></ul>
    20. 20. New Codes In Bariatric Surgery <ul><ul><li>43644 – Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy </li></ul></ul><ul><ul><li>43645 - … with gastric bypass and small intestine reconstruction to limit absorption </li></ul></ul>
    21. 21. Parenteral Nutrition <ul><li>Nutritional supplement </li></ul><ul><li>Also called TPN (Total Parenteral Nutrition) or Hyperalimentation </li></ul><ul><li>Delivered intravenously </li></ul><ul><li>GI tract is bypassed totally </li></ul><ul><li>Liquid goes directly into the bloodstream </li></ul>
    22. 22. Parenteral Nutrition Continued . . . <ul><li>CPT Codes: </li></ul><ul><ul><li>Infusion 90780 and the appropriate number of hours </li></ul></ul><ul><li>HCPCS Codes For Solutions and Supplies: </li></ul><ul><ul><li>B4164 – B5200 </li></ul></ul>
    23. 23. Enteral Nutrition <ul><li>Stomach is partially working, but cannot eat or absorb enough nutrients </li></ul><ul><li>Taken in liquid form via feeding tube </li></ul><ul><li>Must go through part of GI tract </li></ul><ul><li>Delivered directly into stomach or intestines </li></ul>
    24. 24. Enteral Nutrition Continued . . . <ul><li>CPT Codes: </li></ul><ul><ul><li>43752 feeding tube placement requiring physician skill; OR </li></ul></ul><ul><ul><li>90799 if tube place and no physician skill was needed </li></ul></ul><ul><li>HCPCS Codes For Solutions and Supplies: </li></ul><ul><ul><li>B4034 - B4157 </li></ul></ul>
    25. 25. Donor Enterectomy (Intestinal Transplants) <ul><li>CPT Codes: </li></ul><ul><ul><li>44132 - 44721 </li></ul></ul><ul><ul><li>Clarifies the 3 components of physician work </li></ul></ul><ul><ul><ul><li>Cadaver or Living Donor Enterectomy </li></ul></ul></ul><ul><ul><ul><li>Backbench Work </li></ul></ul></ul><ul><ul><ul><li>Recipient Intestinal Allotransplantation </li></ul></ul></ul>
    26. 26. American Society of Transplant Surgeons (ASTS) material <ul><li>New Backbench Codes </li></ul><ul><li> </li></ul><ul><li>This website contains much information on the utilization of transplant codes and process. Highly recommend reviewing too much to paste here! </li></ul>
    27. 27. Billing for Transplants <ul><li>Some of these codes may be new to 2005 and hopefully you have charges in your charge file. </li></ul><ul><li>If no charges, use the “no charge algorithm” to develop the transplant charge </li></ul><ul><li>These procedures are fully billable but you probably will need to have them pre-authorized through some insurance companies. </li></ul>
    28. 28. Rectum <ul><li>CPT Codes: </li></ul><ul><ul><li>45391 and 45392 </li></ul></ul><ul><li>New codes to describe proximal to splenic flexure flexible colonoscopy with endoscopic ultrasound examination </li></ul>
    29. 29. Anus <ul><li>Hemorrhoidopexy </li></ul><ul><ul><li>CPT Code: 46947 </li></ul></ul><ul><ul><li>Method for coding repair of hemorrhoidal prolapse using stapling technique </li></ul></ul>
    30. 30. Screenings Colonoscopies & Medicare <ul><li>G Codes used </li></ul><ul><ul><li>G0121 - Average Risk Patients </li></ul></ul><ul><ul><li>G0105 - High Risk Patients </li></ul></ul><ul><ul><li>Note: If a therapeutic procedure is performed during the screening procedure, use appropriate CPT Code and not the G code. </li></ul></ul><ul><ul><li>(CPT Assistant 1-04, Pages 4-5) </li></ul></ul>
    31. 31. Capsule Endoscopy <ul><li>CPT Code: 91110 </li></ul><ul><ul><li>Capsule swallowed </li></ul></ul><ul><ul><li>Moves thorough GI tract </li></ul></ul><ul><ul><li>Transmits video signals </li></ul></ul>
    32. 32. Modifiers, Modifiers, Modifiers
    33. 33. Procedures not completed are still billable! <ul><li>Use of modifiers and sending documentation will ensure reimbursement! </li></ul><ul><ul><li>52 Reduced Services </li></ul></ul><ul><ul><li>53 Discontinued Procedure </li></ul></ul>
    34. 34. Incomplete Procedures Continued . . . <ul><li>-73 Discontinued Procedure – outpatient hospital, prior to the administration of anesthesia </li></ul><ul><li>-74 Discontinued Procedure – outpatient hospital, after the administration of anesthesia </li></ul>
    35. 35. Coding & Billing Scenarios
    36. 36. Scenario 1 – Mouth & Throat Cancer (see handout) Mr. Smith is admitted to the hospital with a diagnosis of mouth and throat cancer 145.9 and 149.0 . He has a glossectomy (define: Surgical removal of all or part of the tongue.) complete with tracheostomy with unilateral radical neck dissection (41145). A gastronomy, open with construction of gastric tube is also performed (43832). The supplies for the tracheostomy and g-tube are not separately billable for the inpatient portion @ this time. When Mr. Smith is discharged his trach supplies care kit (A4629), speaking valve (L8501) and other supplies in the range of A4623-A4628 may be covered based on carrier requirements. Mr. Smith’s g-tube is for feeling and if and when it needs changing (B4086) with g/j tubing. The enteral supplies such as the feeding supply kit are in the B codes section.
    37. 37. Certification of medical necessity is required for coverage through most insurance companies. Depending on the method of delivery such as pump/gravity/syringe fed these are different kit codes. For example, gravity fed is B4036 for each day. Enteral nutrition is in calories per unit such as 100 cal=1 unit. If Mr. Smith is on an 800 calorie program he will receive 8 units per day. Mr. Smith is receiving blendarized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals and may include fiber (B4149).
    38. 38. Sample Billing codes and Charges 160.00 8 20.00 B4149 45.00 1 45.00 B4086 35.00 1 35.00 L8501 55.00 1 55.00 A4629 800.00 1 800.00 43832 1000.00 1 1000.00 41145 Total charge Units Charge HCPCS codes
    39. 39. Scenario 2 – Abdominal & Digestive Disorders (see handout) Mrs. Jones has a long history of abdominal and digestive disorders. She has GERD, diverticulitis, a bleeding ulcer. She is admitted from the ER to undergo a suture of the large intestine (colorrhapy) for perforated ulcer with colostomy (44605). [She also has 2 units of blood which we will not code here.] Post-operatively she receives all the necessary supplies and education to take care of her ostomy. Mrs. Jones has a non-Medicare primary insurance plan that reimburses for these supplies with a pre-certification call from the billing/UR office. She fills the RX in the pharmacy in 2 weeks for the following supplies: Skin barrier, 4x4 10 units (A4362), Adhesive remover (A4365) 1 unit, Ostomy pouches, drainable with faceplate attached 10 units (A4377) and Ostomy deodorant tablets 10 units (A4395). If Mrs. Jones had Medicare Primary and a supplemental/secondary plan it would also require a medical necessity form and the billing office could not bill electronically for these supplies .
    40. 40. Sample Billing codes and Charges Total charge Units Charge HCPCS codes 10.00 10 1.00 A4395 150.00 10 15.00 A4377 6.00 1 6.00 A4365 20.00 10 2.00 A4362 1000.00 1 1000.00 44605
    41. 41. Scenario 3 – Headache, Jaw Pain, Sleeping Problem (see handout) Mr. Stanley presents with complaints of headache, jaw pain, difficulty sleeping and jaw locking. Other conditions are ruled out and the diagnosis is Temporal Mandibular Joint Disease (Disorder) TMJ. Mr. Stanley also has 2 non-erupted wisdom teeth that are contributing to the problem. Mr. Stanley is treated at the minor surgery wing of the dental suite at the medical center. First, the tow impacted teeth partially boney (D7230) are extracted with nitrous oxide for anesthesia. Next, a TMJ arthroscopy (D7874) with disc repositioning and stabilization is completed (see also 29804). Mr. Stanley is discharged late that day to his home with an RX for a surgical splint (D5988) which he picks up in the prosthetic department. Mr. Stanley has BCBS and Delta Dental for insurance. All items are to be sent to Delta Dental. If Mr. Stanley had Medicare primary, the procedure would be paid with Medicare prime but Medicare does not cover the splint so that is covered by Delta Dental as primary.
    42. 42. Sample Billing codes and Charges Total charge Units Charge HCPCS codes 100.00 1 100.00 D5988 1000.00 1 1000.00 29804* 1000.00 1 1000.00 D7874 1000.00 2 500.00 D7230
    43. 43. References <ul><li>Coding Clinic </li></ul><ul><li>CPT Assistant </li></ul><ul><li>CPT Changes 2005 </li></ul><ul><li>ICD Changes 2005 </li></ul><ul><li>Faye Brown’s ICD Coding Handbook </li></ul>
    44. 44. Continuing Education Credit <ul><li>AHIMA – self report 1 hour </li></ul><ul><li>AAPC – Preapproved for one hour report #DVAEES0505041119 </li></ul><ul><li>Reference: http:// = </li></ul>
    45. 45. Questions/Comments/Concerns <ul><li>Denise.Hamilton @ </li></ul><ul><li>Joletta.Maxile @ </li></ul><ul><li>Vickie.Nitschke @ </li></ul><ul><li>Barbara.Millas @ </li></ul>