+ Janet McCauley, MD, MHA, CPC, FACOG April 6, 2019
+ Background Evaluation and Management “E&M” Problem oriented Consultations Preventive services Coding examples
+ Surgical Coding Modifiers Obstetrical Global Ultrasound Coding Examples
+ Thank you Dr. Craig Sobolewski for contribution of Surgical Coding Scenario
+ CPT Global Package Includes: Preoperative —Services beginning one day prior Intra-operative —All usual intra-operative procedures Postoperative -- Related visits for: 0 or 10 days (minor procedure) 90 days (major procedure) May use CPT 99024 for EM visits during post op period for reasons related to original procedure
+ Does not include: Intra-operative —Unrelated procedures Post-operative Visits unrelated to the diagnosis for surgery Services for added course of treatment Care from physicians/QHPs outside surgical group or another specialty within multispecialty group
+ Modifiers
+ - 22 Unusual services -51 Multiple procedures Exceptions: Add-on codes Separate procedure designation by CPT -59 Distinct procedural service -58 Staged or related procedure in post op period -79 Unrelated procedure by same surgeon during post op period Appended to procedure code
+ -24 Unrelated E/M service in post op period -25 Significant, separately identifiable E/M by same physician or other qualified health professional, on same day as procedure -57 Decision for surgery Appended to EM code
+ Modifier Description 80 Assistant Surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon (when qualified resident not available) 62 Two Surgeons (co-surgery) 66 Surgical Team AS PA, NP, or CNS services for assistant-at-surgery (Medicare) From ACOG Coding Workshop Gynecological Surgical Coding 2017
+ Surgeons working together to perform distinct parts of a single procedure Each surgeon has key role in the performance of the procedure Both surgeons report same CPT code and modifier Co-surgeon may also serve as assistant on additional procedures
+ 58200 TAH, partial vaginectomy, para-aortic and pelvic lymph node sampling with/without removal of tubes/ovaries General Gynecologist: Hysterectomy Gynecologist/Oncologist: Lymph nodes Each reports same code, same modifier and own established fee
+ Ms. Potter is a 22-yo who presents to the ER on 12/24 with c/o vaginal bleeding, abdominal pain, and fever. LMP is 3 weeks late. Dr. Benjamin B, the ER physician orders a stat hCG and U/S and consults Dr. Peter R, the on-call GYN. Pelvic exam reveals normal uterus and right adnexal tenderness. Stat hCG is 4000 mIU/mL. U/S in the radiology department reveals an empty uterus and a 2.5 cm mass near the right ovary. Dr. Peter R diagnoses an ectopic pregnancy and takes Ms. Potter to the OR that day for laparoscopic treatment.
+ Intraoperatively, severe pelvic adhesions are encountered. VS remain stable. Dr. Cottontail, a general surgeon, is called to assist with adhesiolysis. 60 minutes of adhesiolysis is required in order to identify the right adnexa. A right salpingectomy is performed by Dr. Peter R. The appendix appears swollen and injected. Dr. Cottontail performs an appendectomy. Ms. Potter does well and is d/c’ed home the following day. One week later. Ms. Potter is seen by Dr. Peter R for a c/o of right breast tenderness
+ On 12/24: Dr. Peter R 9924X-57 Outpatient consultation, decision for surgery same day 59151-22 Laparoscopic tx of ectopic w/ salpingectomy and/or oophorectomy 44970-80(2nd) Dr. Cottontail 44970-22 Laparoscopic appendectomy 59151-80(2nd) One week later: Drs. Peter R and Cottontail Dr. Peter R 9921X-24 Established office/outpt visit, unrelated to surgery
+ On 12/24: 9924X-57 O00.90 Unspecified ectopic w/out IUP Z3A.01 Less than 8 weeks gestation of pregnancy 59151-22 O00.101 R Tubal pregnancy w/out IUP Z3A.01 N73.6 Pelvic adhesions, female 44970-22 K35.80 Unspecified acute appendicitis N73.6 Pelvic adhesions, female Drs. Peter R and Cottontail One week later: 9921X-24 N64.4 Mastodynia
+
+ 59400 Routine care, antepartum, vaginal delivery, postpartum care 59510 Routine care, antepartum, cesarean delivery, postpartum care 59610 Routine care, antepartum, vaginal delivery, postpartum care, after prior CS 59618 Routine care, antepartum, cesarean delivery, postpartum care, attempted vaginal after prior CS
+
+ Included: Excluded: Up to 13 pregnancy related Diagnosis of pregnancy outpatient visits Medical or surgical conditions unrelated to pregnancy Visit where OB record initiated Z33.1 “pregnancy state, incidental” as secondary diagnosis may or may not Routine screening bundle Some payers may include Inpatient and outpatient allowance for diagnostic hospitalization testing (ex. ultrasound, NST)— payer specific Ultrasound and monitoring
+ Included: Excluded: Admission H&P within 24 Hospital observation or hours of delivery admission, and subsequent visits, more than 24 hours Uncomplicated labor before delivery Induction External cephalic version Cervical dilator placed same day Cervical dilators placed day Simple cerclage removal before delivery Delivery of infant and Delivery of Twin B placenta May be payer specific
+ Included: Excluded: Visits to treat Post delivery inpatient complications or disease care unrelated to routine pp Vag Del: 2 days care CS: 4 days Delayed hemorrhage Wound infection Postpartum outpatient Other med/surg conditions visit Vag Del: 1-2 visits within 6 Inpatient conditions weeks requiring care > 2 (Vag Del) or 4 (CS) days CS: 2 visits
+ Report after delivery: additional E/M services if >13 antepartum visits (may be payer specific) Report at time of service Additional diagnostic testing or procedure Hospital admission or observation when discharged undelivered (unless returns for delivery <24 hrs) Don’t report additional visits related to previous history unless problem develops
+ Use for transfers of care and pregnancy loss Do NOT use for coverage Options: Less than 4 antepartum visits: Use E/M code 4-6 antepartum visits: 59425 7+ antepartum visits: 59426 Delivery only: 59409, 59514, 59612, 59620 Does not include inpatient pp care Delivery and pp care: 59410, 59515, 59614, 59622 Placenta only: 59414 Postpartum only: 59430
+ All OB codes found in Chapter 15 in ICD-10-CM (Codes O00-O9A) Many require 7 th character to identify fetus with complication Codes from O09 for supervision of high risk pregnancy: list first for outpatient visits Codes O00-O9A require additional Z3A.** codes to identify gestational age Codes in ICD-10-CM distinguish: Conditions prior to pregnancy vs. conditions as result of pregnancy High-risk pregnancies vs. complications during delivery
+ Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Status codes History (of) Screening Observation Counseling Encounters for obstetrical and reproductive services, including weeks of gestation and supervision of normal pregnancy Used for many types of services, not just OB: Such as: Routine care, reason for screening test, risk factors, follow-up
+ Diagnostic and procedure code combinations tell: Why (missed ab vs. complete vs. incomplete vs. induced vs. ectopic) When (termination vs. delivery code) How (surgical vs. medical) Which procedure (D&C, D&E, injection, suppository) Be aware of benefit coverage limits for elective and therapeutic terminations
+
+ Professional Technical Component Component (26) (TC) Supervision of test Technician salary/benefits Interpretation Equipment Written report Supplies Use -26 when interpreting Facility uses –TC when you study where facility or other interpret study instead of entity owns equipment and radiologist pays tech If you own machine and Do not use if radiologist employ technician, do not provides report report either modifier
+ CPT 76801-76817 Specific components required (+) codes for each additional gestation Code relevant and most specific diagnosis O09 series “Supervision of high risk pregnancy” as only diagnosis may or may not be recognized Z03.7(+5 th digit) series “Encounter for suspected maternal and fetal conditions ruled out” may be needed for some referrals
+ 76830 (TV), 76856 (Abd), 76857 (Abd limited) 76831/58340 (SIS), 74740/58340 (HSG) Needs separate record and permanent image Don’t report when used to complete physical exam
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