Thursday, March 18, 2010

Topaz Procedure

Question: Our surgeon excised a portion of the patient’s Achilles tendon, reanastomosed the tendon using running sutures, and then used the TOPAZ procedure to augment the repair. The patient’s tendon wasn’t torn or ruptured. How should we code this procedure?

Answer: Because the tendon in this case isn’t torn or ruptured, you should report 27680 (Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon). CPT includes several codes for Achilles tendon repair, so know how to differentiate them according to your case. Keep these guidelines from the American Orthopaedic Foot and Ankle Society (AOFAS) in mind:
• For debridement of insertional Achilles tendinitis and repair (suture anchor versus bony trough), choose code 27680.
• For Achilles tendon debridement and repair for tendonosis, choose 27654 (Repair, secondary, Achilles tendon, with or without graft).
• For Achilles tendon debridement with FHL transfer and tenodesis FHL to FDL, choose 27680 and 27691 (Transfer or transplant of single tendon [with muscle redirection or rerouting]; deep [e.g., anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot).
• For repair of the Achilles tendon to calcaneus for traumatic avulsion, choose 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon).
Definition: TOPAZ is a new micro-ablator technique for soft tissue procedures. According to CPT Assistant, consider the TOPAZ as any other technique and code accordingly — by choosing the most accurate code from the above list.

Ulnar Impaction Syndrome Dx

Ulnar Impaction Syndrome Diagnosis
The best choice is 718.83 (Unspecified derangement of joint; forearm) to represent instability.
The most common surgical options to treat ulnar impaction syndrome (after physical therapy or other modalities have failed) include an ulnar shortening osteotomy (25390, Osteoplasty, radius or ulna; shortening) and hemiresection arthroplasty (25442, Arthroplasty with prosthetic replacement; distal ulna). Depending on the situation, your surgeon might perform resection of the distal ulna (25240, Excision distal ulna partial or complete [e.g., Durrach type or matched resection]) or an arthroscopic wafer procedure (29999, Unlisted procedure, arthroscopy).

Ulnar impaction syndrome is also known as ulnar abutment syndrome, and can be a common complication after distal radial fracture. The term means the distal ulna is no longer in line with the distal radius, resulting in the ulna being longer. The ulnar weight bearing load increases and causes chronic pain on that side of the wrist

Orthopedic Newsletter Jan. 2010

Thursday, May 8, 2008

Coding of Unsuccessful procedures

There may be some confusion as to how we handle the coding of "unsuccessful" procedures. These situations occur mainly in the Emergency Room setting.
Coding Guidelines:

If there are unsuccessful procedures, followed by a successful same procedure, only the successful one is picked up. (Example, fracture reductions attempted in the ER and the pt ends up having to go to OR)

If an unsuccessful procedure is performed in its entirety, but the desired result is not obtained, then we still pick that up with no modifier. (Example, LP with no CSF obtained)

Foreign body removal from ear (bug) was unsuccessful. This would be a coded procedure. It was done.

If you come across other examples please forward to me and I can add to the above list.

Tuesday, April 8, 2008

Application of air cast

The following information published in the most recent issue of Coding Clinic for HCPCS will change how we handle the application of a splint.

Coding Clinic for HCPCS - Fourth Quarter 2007 Page: 5Question 2
In the First Quarter 2007 issue of Coding Clinic for HCPCS, it was advised that if a splint is applied, it would be appropriate to report a CPT code for application of the splint regardless of whether the splint was off the shelf and/or prefabricated. I understand that items such as post-op shoes, slings, and ace bandages do not meet the criteria of a splint and are not separately reportable. How should the application of an air cast be reported? Does it meet the criteria for splint application or is this not a separately reportable service?

For hospital outpatient reporting, the application of the air cast would be inclusive in the code for the visit or procedure and would not be separately reported. The appropriate HCPCS level II code for the air cast can be reported when no restorative treatment or procedure (specific to that injury) is performed or expected to be performed.

For all Memorial Hermann Coders- Effective Feb. 27, 2008 we will no longer assign a code for the application of an air cast.

Tip: Don't let your Encoder do all the work for you!

Relying on an encoder can potentially result in an increased prevalence and incidence of clinically incorrect principal and secondary diagnoses. This can create an inaccurate reflection of the acuity, risk of morbidity and mortality, and hospital resource consumption and result in inaccurate reimbursement for the hospital.

Take steps to improve upon deficiencies in clinical acumen, include researching new disease processes on the Internet and requesting adequate clinical resource materials in the coding department. Coders who possess the drive, self-discipline, and initiative to take these steps will make a successful transition from an average coder to a clinically astute professional coder.

Friday, November 2, 2007

Laser Treatment of Vesicle Neck Contracture

You Be the Coder
Which code should I use for holmium laser of a vesicle neck contracture?

Your coding for treatment of a bladder neck contracture (596.0) by holmium laser depends on the etiology of the bladder neck contracture.

Option 1: If the bladder neck contracture is secondary to benign prostatic hypertrophy present
predominately at the bladder neck, as often seen in younger men with obstructive symptoms, you should report 52450 (Transurethral incision of prostate).
Code 52450 represents an incision of the prostatic urethra, usually extending from and including the bladder neck to the verumontanum, the complete prostatic urethra.

Option 2: If the bladder neck contracture is secondary to a previous prostate surgery, such as an overzealous transurethral resection of the prostate [TURP] at the bladder neck, you'll instead use 52640 (Transurethral resection; of postoperative bladder neck

Option 3: If the bladder neck contracture occurs after a radical prostatectomy, which is in fact a urethral stricture at the vesicourethral junction, you should report 52276 (Cystourethroscopy with direct vision internal urethrotomy).

Note: You should use the above codes for any type of therapy and technology used for treating the bladder neck contracture, whether a laser, hot knife, cold knife or a single resection groove.

Tuesday, August 28, 2007

Insertion of Pain Pump

Do not assign a separate CPT code for the insertion of an "On-Q pain pump".

This is inclusive in the procedure that is being done.

Many times I see the CPT code 37205 used.

Wednesday, July 25, 2007

Coding Endoscopy px when done on ER pt

Current process to follow:
Some of the facilities have ER patients who are having endoscopy procedures performed in the endoscopy suite or in the ER. We also have some ER patients who go to the operating room for procedures and then are discharged as an ER patient.
* An ER patient who had a proctoscopy performed in the Emergency room
* An ER patient who went to the endoscopy suite and had an endo procedure performed and discharged as ER patient type
* An ER patient who went to the operating room for a procedure and discharged as ER patient type

We went through what would be charged through the charge master and what the ER coders would be responsible for coding and reporting using Power Abstract and came up with the following:
* ER patient type with operating room charges: ER coder will code both ER procedures and operating room procedures and enter in PA

* ER patient type with Endoscopy procedures: ER coder will code endoscopy procedures performed either in ER (proctoscopy) or the endoscopy suite

Monday, July 23, 2007

64483, 64484

Clinical Example: The patient has a herniated disc at the L4-L5 with scar tissue; compatible with an acute L5 radiculopathy. He undergoes a bilateral transforaminal epidural injection of an anesthetic agent and/or steroid at the L5-S1 level.

Correct CPT Codes: 64483-50

Coding tip:
A transforaminal epidural spinal injection technique is a technically different approach from central epidural injection. Because the vertebral artery as well as the spinal cord is close to the nerve root, this procedural technique is more difficult than a central epidural injection.

Clinical Example: The pt's recent MRI shows acute radiculopathy at the L4 and L5. He undergoes a bilateral transforaminal epidural steriod injection at the L4-L5 and L5-S1 levels.

Correct CPT Codes: 64483-50 and 64484-50


Clinical Example: Pt presented with a long history of cervical spine pain in her neck. A recent x-ray showed cervical spondylosis between the left C5-C6.
Pt undergoes left cervical facet joint injection with corticosteriod into the cervical facet joint at C5-C6.

Correct CPT code assignment: 64470-LT

64470 is a unilateral procedure. When injections are performed at both the right and left paravertebral facet joints or paravertebral facet joint nerves, append modifier 50 to the code.

Wednesday, June 20, 2007

Treatment of ureteral stricture

Coding Trivia

Q: Which CPT code should you report for a cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision)?

A: 52344

Monday, June 11, 2007

780.39 vs 345.90

The question asked: When is code 780.39 used anymore? I was told to use 345.90 even if epilepsy wasn't documented.

Answer: So much depends on the MD's documentation for the seizure. As of 10/1/06 the index changed so that now a "seizure disorder" is classified with the epilepsy codes. We have to follow the updated index and use it based on the documentation we have. Indexing: "Disorder / seizure", and "Seizure / recurrent" now go to 345.90, while indexing "Seizure / repetitive" goes to 780.39. Here is what I found out at a Neurology Inservice that I recently attended. The index changes were discussed. The national association of neurologists are in the process of changing the definition of epilepsy. The new definition will be more than one seizure (without any known cause, like a sudden head injury, high fever, or severe metabolic problem) occuring over a period of time (such as months or years.) That's why ICD-9 has classified a seizure disorder or recurrent seizures to 345.90. And it's probably why "repetitive" still codes to 780.39, since the repetitive seizures might actually all be a part of one episode of seizures (given that they probably aren't separated by months or years.)

So make your code assignment of either 780.39 or 345.90 based on what the MD has stated, but if that isn't clear -- then query. Coding Clinic has not addressed the 10/1/06 index changes, but we still have to follow the index as any index change would supercede the older CC92Q4 advice.

Thursday, May 17, 2007

V61.5 & V25.2

When a pt comes in for a tubal ligation, use V25.2 as your first listed dx code.

I have seen V61.5 being used. According to the ICD-9-CM Coding book, this is an unacceptable principle dx.

Colonoscopy Guidelines

AHA reply 2/19/09

Assign Code V67.09, Follow-up exam, as the first listed dx for the colonoscopy encounter described below in example #1. Assign code V12.72, Personal history of Colonic Polyps, as a secondary dx.

Ex, #1: Previous h/o polyps. No new polyps are found.

If, however, a condition is found to have recurred on this follow-up visit, then the diagnosis code is assigned in place of the follow-up code. See example #2.

Ex. 2: Previous h/o polyps. New colon polyps are found. First listed dx code will be 211.3
Do not assign V12.72 since polyps are now current.

Wednesday, May 16, 2007

Favorite weblinks

American Academy of Professional Coders-

American Health Information Management Association-

Just Coding - (requires membership to access most items. Let me know if something looks interesting and I can obtain for you)

American Hospital Association -

Advance for Health Information Professionals-

For The Record -

TrailBlazer -

send me any of your favorites...JJ

Tuesday, May 15, 2007

EGD with polypectomy

A question I submitted to Coding Clinic AHA has been published in their First Quarter 2007 "Coding Clinic for HCPCS" newsletter.
Question: Pt has EGD with gastric polypectomy. Polypectomy performed with cold bx forceps. What is correct CPT code?

Answer: Report CPT code 43258.

LEEP 57522

LEEP procedure is coded 57522. The px is rarely done using a Colposcopy. I have seen CPT code 57460 used but no evidence of a colposcopy being used.