Coding Strategy

Question: Documentation reads, “The cyst was excised after performing a central incision directly on the cyst. All the material was expressed, then cyst capsule was removed completely and excised completely. Packing was performed.” Should I code the procedure as an I&D or an excision?

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Answer: You should look at the pathology report and any further excision description to reach the correct code set. “Excision is defined as full thickness [through the dermis] removal of a lesion …,” according to CPT’s Excision-Benign Lesions guidelines. The documentation you provided does not indicate what tissue levels the excision involved. A cyst can be epidermal or sebaceous (706.2). A lesion that is removed from the epidermis (top skin layer) does not meet CPT’s excision definition.

The sebaceous gland extends through the dermis. Excision that deep would qualify for an excision code. An excision code (such as 11400, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) requires further documentation detailing the lesion’s morphology, size (including margins), and anatomical location. Without this information, the I&D code (10060, Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) may be more appropriate. The physician made a cut to drain the cyst and then drained (expressed) all the material. The cyst capsule removal is part of the treatment of the I&D to prevent the blockage from reoccurring.

Take more coding challenges with Family Practice Coding Alert. Written by Jen Godreau, BA, CPC, CPEDC, content director of Supercoder.com, Family Practice Coding Alert, Volume 12, Number 6.

Hint: Abnormal versus insufficient cells mean different diagnosis codes.

When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.

Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
 
Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?

Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?

Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?

Answer 1: Here’s What CPT Codes
 
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit becausethe patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer

Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M service, and you should not code for it separately.
In addition, Medicare will not reimburse for Q0091 (Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) for the repeat Pap smear because it is a diagnostic test. In this case, Medicare considers the service a problem E/M, not a preventive screening, and the specimen collection is part of the E/M service.

Answer 3: Use 795.0X for Abnormal Results

You should report 795.0x (Abnormal Papanicolaou smear of cervix and cervical HPV) if the ob-gyn repeats the Pap smear due to abnormal results.This code requires a fifth digit, points out Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders. If you don’t include the fifth digit, this “could be a reason for a denial,” she adds.

For example, a 35-year-old woman with multiple sexual partners presents for an annual exam. She has not had a Pap smear in four years. The Pap results return ASC-US, and the physician asks her to come back in three months for a repeat Pap to follow any abnormal cell progress. When the patient returns, you should code the appropriate E/M office visit with 795.01 because the Pap is repeated due to abnormal cells.

Answer 4: ‘Inadequate Sample’ Means a Different Code

On the other hand, if the patient requires a second Pap smear because the first sample was inadequate (that is, the lab did not have enough cells in the specimen to interpret the results), you can use one of two codes. Report V76.2 (Special screening for malignant neoplasms; cervix) or 795.08 (Unsatisfactory cervical cytology smear) if the first smear was inadequate, says Karen O’Malley, office manager of an ob-gyn practice in Arlington Heights, Ill.

In the notes associated with 795.08, the ICD-9 manual indicates you can use this code for “unsatisfactory smear.” For example, the patient is menopausal and the physician does not reach the transformation zone. The Pap result indicates only a few cells (not enough to analyze), and the physician likely would require another Pap. The physician may consider this as just a second screening Pap smear, or may decide to report the available code for an unsatisfactory smear instead. Medicare would require V76.2 as the code for this situation.

ICD-10: You’ll have to use new codes when your diagnosis system changes in 2013. They are:

• 616.10=N76.0 (Acute vaginitis) or N76.1 (Subacute and chronic vaginitis),
• 795.0x=R87.61x (Abnormal cytological findings in specimens from cervix uteri),
• V76.2=Z12.4 (Encounter for screening for malignant neoplasm of cervix), and
• 795.08= R87.615 (Unsatisfactory cytologic smear of cervix).

Take more coding challenges in Ob-Gyn Coding Alert.

By: Suzanne Leder, M.Phil., CPC, COBGC, executive editor of Ob-Gyn Coding Alert, 2010; Volume 13, Number 6.

Hint: Abnormal versus insufficient cells mean different diagnosis codes.

When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.

Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
 

Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?
Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?

Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?

Answer 1: Here’s What CPT Codes

 
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit because the patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer

Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M service, and you should not code for it separately.
In addition, Medicare will not reimburse for Q0091 (Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) for the repeat Pap smear because it is a diagnostic test. In this case, Medicare considers the service a problem E/M, not a preventive screening, and the specimen collection is part of the E/M service.

Answer 3: Use 795.0X for Abnormal Results

You should report 795.0x (Abnormal Papanicolaou smear of cervix and cervical HPV) if the ob-gyn repeats the Pap smear due to abnormal results.This code requires a fifth digit, points out Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders. If you don’t include the fifth digit, this “could be a reason for a denial,” she adds.

For example, a 35-year-old woman with multiple sexual partners presents for an annual exam. She has not had a Pap smear in four years. The Pap results return ASC-US, and the physician asks her to come back in three months for a repeat Pap to follow any abnormal cell progress. When the patient returns, you should code the appropriate E/M office visit with 795.01 because the Pap is repeated due to abnormal cells.

Answer 4: ‘Inadequate Sample’ Means a Different Code

On the other hand, if the patient requires a second Pap smear because the first sample was inadequate (that is, the lab did not have enough cells in the specimen to interpret the results), you can use one of two codes. Report V76.2 (Special screening for malignant neoplasms; cervix) or 795.08 (Unsatisfactory cervical cytology smear) if the first smear was inadequate, says Karen O’Malley, office manager of an ob-gyn practice in Arlington Heights, Ill.

In the notes associated with 795.08, the ICD-9 manual indicates you can use this code for “unsatisfactory smear.” For example, the patient is menopausal and the physician does not reach the transformation zone. The Pap result indicates only a few cells (not enough to analyze), and the physician likely would require another Pap. The physician may consider this as just a second screening Pap smear, or may decide to report the available code for an unsatisfactory smear instead. Medicare would require V76.2 as the code for this situation.

ICD-10: You’ll have to use new codes when your diagnosis system changes in 2013. They are:

• 616.10=N76.0 (Acute vaginitis) or N76.1 (Subacute and chronic vaginitis),
• 795.0x=R87.61x (Abnormal cytological findings in specimens from cervix uteri),
• V76.2=Z12.4 (Encounter for screening for malignant neoplasm of cervix), and
• 795.08= R87.615 (Unsatisfactory cytologic smear of cervix).

Take more coding challenges in Ob-Gyn Coding Alert.

By: Suzanne Leder, M.Phil., CPC, COBGC, executive editor of Ob-Gyn Coding Alert, 2010; Volume 13, Number 6.

Incident-to services are on auditors radar. To prevent paybacks, you’ve got to know when to use incident to – and capture full pay, and when to bill services directly – and lose the standard 15%. Test your incident to savvy with this question:

Question: Can an NP see a new patient in the office under incident to?

Answer: Check out the solution.

P.S. Got a coding stumper? The Coding Institute CPC staff provide fast, easy-to-understand answers – with a M-F 24-hour turnaround!

With multiple ways to denervate the sensory nerve/nerve branches, pain management coders may argue about which 64xxx code is right. You’ve got to dig into the chart note to identify the method used. See if you’re up to the challenge with this Supercoder Forum Insight.

Question: A provider is doing RFA’s of the left L4, L5, S1, S2, S3 and SA. He is billing 64622 x 1 and 64623 x 4. The other pain provider states this is incorrect and that he should be billing 64640 for S1, S2, S3 and SA. Which coding is correct?

Answer: This is a complex coding issue because there are several different methods to denervate the sensory nerve/nerve branches that provide innervations from the SI joint. Because of this, the coding will depend somewhat on the method used.

However, I can say that reporting 64622 and 64623 x 4 is incorrect. The “paravertebral facet joint nerves” that provide innervations to the facet joints in the cervical, thoracic, and lumbar regions are the medial branches off the dorsal ramus. In the sacrum, there are indeed medial branches, but – as their name indicates – the path for these nerve branches is to the midline to provide innervations to the multifidus muscles and not laterally to the SI joint. So, following the published CPT Instructions for Use of the CPT Codebook – “Do not select a CPT code that merely approximates the service provided”, even though they are similar, procedures performed on the lateral branches of the sacral nerves should not be reported as paravertebral facet joint nerve procedures (i.e., paravertebral facet joint injections or destructions).

A few of the more common techniques are:

• Separate destruction of each nerve/nerve branch. According to CPT Assistant (Dec. 2009), you would code 64622 for the L5 dorsal ramus and 64640 x 3 for the individual lateral S1, S2, and S3 branches. If the provider also does an RF ablation of the L4 medial branch, add 64623 x 1 for destruction of that facet joint nerve.
• Destruction of the sacral nerves via placement of a single RF probe midway between the lateral border of the sacral foraminal openings and the medial border of the SI joint. The single RF probe has multiple active electrodes. Code with 64999 (per CPT Assistant, Dec. 2009) because the technique and physician work are much different from the multiple separate destructions.
• Destruction of the sacral nerves via a “strip lesion” along the posterior border of the SI joint or insertion of the RF probe(s) into the posterior SI joint. In private response to a pain management practice’s paid question, the CPT Knowledgebase responded that this type of technique would also be reported with 64999.
  So, as is often the case, the coding answer will be “it depends!” Once you know which method your doctor used, you can decide on the correct code. Check out CPT Assistant Q/A (Dec. 2009) for more details on coding for the different methods. And you could always send the question to the CPT Knowledgebase and get a written answer for your physician.
  From: Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO