00 A TPR Prelim .fm Page 1 Friday,N ovem ber14,2008 12:52 PM
Coding Companion for Plastics/OMS/Dermatology A comprehensive illustrated guide to coding and reimbursement
2009
00 A TPR TO C.fm Page i Friday,N ovem ber14,2008 1:00 PM
Contents Getting Started with Coding Companion ............................. i Skin ..................................................................................... 1 Nails.................................................................................. 28 Pilonidal Cyst..................................................................... 32 Repair................................................................................ 33 Destruction ..................................................................... 136 Breast .............................................................................. 149 General Musculoskeletal .................................................. 172 Head ............................................................................... 187 Neck................................................................................ 299 Humerus/Elbow............................................................... 300 Forearm/Wrist.................................................................. 301 Hand/Fingers................................................................... 314 Endoscopy....................................................................... 346 Nose ............................................................................... 349 Arteries/Veins................................................................... 356
Lips ................................................................................. 359 Vestibule of Mouth .......................................................... 372 Tongue............................................................................ 385 Dentoalveolar Structures ................................................. 413 Palate/Uvula .................................................................... 426 Abdomen ........................................................................ 460 Extracranial Nerves.......................................................... 462 Ocular Adnexa ................................................................ 482 External Ear ..................................................................... 507 Operating Microscope..................................................... 508 Medicine Services............................................................ 509 Appendix ........................................................................ 514 CCI Edits ......................................................................... 526 Evaluation and Management .......................................... 527 Index............................................................................... 549
© 2008 Ingenix
Coding Companion for Plastics/OMS/Dermatology
Contents
15780-15781
15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 segmental, face
701.9 Unspecified hypertrophic and atrophic condition of skin 702.0 Actinic keratosis 702.11 Inflamed seborrheic keratosis 706.0 Acne varioliformis 706.1 Other acne 709.2 Scar condition and fibrosis of skin 906.0 Late effect of open wound of head, neck, and trunk 908.6 Late effect of certain complications of trauma 909.3 Late effect of complications of surgical and medical care V50.1 Other plastic surgery for unacceptable cosmetic appearance
Terms To Know Repair
acne. Inflammatory skin disease affecting the sebaceous glands and hair follicles resulting in comedones, papular, and pustular skin eruptions.
rosacea. Skin disease involving the face, characterized by redness and permanent dilation of small blood vessels, with outbreaks of edema and pustule formation.
CCI Version 14.3
36000, 36410, 37202, 51701-51703, 62318-62319, 64415-64417, 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, 90775 Also not with 15780: 11010-11011, 15781 Also not with 15781: 11010 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above.
Medicare Edits Fac Non-Fac RVU RVU FUD Assist e 16.56 20.55 90 15780 10.76 13.05 90 15781 N/A Medicare References: 100-2,16,10; 100-2,16,120; 100-2,16,180; 100-4,12,30
actinic keratosis. Flat, scaly precancerous lesions appearing on dry, sun-aged, and overexposed skin, including the eyelids.
Explanation
The physician performs dermabrasion of the total face in 15780 for conditions such as acne scarring, fine wrinkling, rhytids, and general keratoses. The physician uses a powered rotary instrument to sand down or smooth scarred or wrinkled areas. The physician lowers raised lesions or thins thickened tissue to regenerate skin with a smoother appearance. Report 15781 for a dermabrasion performed on one segment of the face.
Coding Tips Because these procedures are sometimes not done out of medical necessity, the patient may be responsible for charges. Verify with the insurance carrier for coverage. For cryotherapy for acne, see 17340; chemical exfoliation for acne, see 17360.
atrophy. Reduction in size or activity in an anatomic structure, due to wasting away from disease or other factors. cosmetic. Superficial or external, having no medical necessity. cryotherapy. Any surgical procedure that uses intense cold for treatment. dermabrasion. Cosmetic procedure that smooths out flaws and disfigured skin and promotes the growth of a new layer of skin cells by removing the outer layer of skin by mechanical or chemical means such as fine sandpaper, wire brushes, and caustic substances. fibrosis. Formation of fibrous tissue as part of the restorative process.
86.25 Dermabrasion
granulation tissue. Loose collection of fibroblasts, inflammatory cells, and new vessels in an edematous fleshy projection that forms at the base of open wounds over which new skin forms, unless excessive granulation tissue, or proud flesh, rises above the wound surface.
Anesthesia
hypertrophic. Enlarged or overgrown from an increase in cell size of the affected tissue.
ICD-9-CM Procedural
00300
ICD-9-CM Diagnostic 695.3 Rosacea 701.5 Other abnormal granulation tissue 701.8 Other specified hypertrophic and atrophic condition of skin
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106 — Repair
late effect. Abnormality, dysfunction, or other residual condition produced after the acute phase of an illness, injury, or disease is over. There is no time limit on when late effects can appear. rhytids. Wrinkles or wrinkling of the skin.
CPT only © 2008 American Medical Association. All Rights Reserved.
Coding Companion for Plastics/OMS/Dermatology
41000
41000 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
920
Contusion of face, scalp, and neck except eye(s)
958.3 Posttraumatic wound infection not elsewhere classified 998.12 Hematoma complicating a procedure 998.59 Other postoperative infection — (Use additional code to identify infection)
Terms To Know abscess. Circumscribed collection of pus resulting from bacteria, frequently associated with swelling and other signs of inflammation. cellulitis. Sudden, severe, suppurative inflammation and edema in subcutaneous tissue or muscle, most often caused by bacterial infection secondary to a cutaneous lesion. cyst. Elevated encapsulated mass containing fluid, semisolid, or solid material with a membranous lining. glossitis. Inflammation and swelling of the tongue that may be associated with infection, adverse drug reactions, smoking, or injury. glossodynia. Tongue pain.
Explanation The physician makes a small intraoral incision through the mucosa of the tongue or floor of the mouth overlying an abscess, cyst. The abscess, hematoma, or cyst is opened with a surgical instrument and the fluid is drained.
Coding Tips Local anesthesia is included in the service. For incision and drainage of a sublingual cyst, see 41005 or 41006.
ICD-9-CM Procedural 25.94 Other glossotomy 27.0 Drainage of face and floor of mouth
Anesthesia 41000 00170
ICD-9-CM Diagnostic
incision. Act of cutting into tissue or an organ. lingual. Surface of the tooth closest to the tongue or relating to the tongue and its surrounding areas.
CCI Version 14.3
00170, 10060-10061v, 10160, 36000, 36410, 37202, 49424, 51701-51703, 62318-62319, 64415-64417, 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, 90775, 92502 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above.
Medicare Edits Fac Non-Fac RVU RVU FUD 2.81 3.88 10 41000 Medicare References: None
Assist N/A
Tongue
528.3 Cellulitis and abscess of oral soft tissues 528.4 Cysts of oral soft tissues
hematoma. Tumor-like collection of blood in some part of the body caused by a break in a blood vessel wall, usually as a result of trauma.
529.0 Glossitis 529.6 Glossodynia 529.8 Other specified conditions of the tongue 750.19 Other congenital anomaly of tongue 780.62 Postprocedural fever 784.2 Swelling, mass, or lump in head and neck CPT only © 2008 American Medical Association. All Rights Reserved.
Coding Companion for Plastics/OMS/Dermatology
© 2008 Ingenix
Tongue — 385
04 A TPR EM .fm Page 527 Friday,N ovem ber14,2008 2:39 PM
This section provides an overview of evaluation and management (E/M) services, tables that identify the documentation elements associated with each code, and the federal documentation guidelines with emphasis on the 1997 exam guidelines. This set of guidelines represent the most complete discussion of the elements of the currently accepted versions. The 1997 version identifies both general multi-system physical examinations and single-system examinations, but providers may also use the original 1995 version of the E/M guidelines; both are currently supported by the Centers for Medicare and Medicaid Services (CMS) for audit purposes. Although some of the most commonly used codes by physicians of all specialties, the E/M service codes are among the least understood. These codes, introduced in the 1992 CPT® manual, were designed to increase accuracy and consistency of use in the reporting of levels of non-procedural encounters. This was accomplished by defining the E/M codes based on the degree that certain common elements are addressed or performed and reflected in the medical documentation. The Office of the Inspector General (OIG) Work Plan for physicians consistently lists these codes as an area of continued investigative review. This is primarily because Medicare payments for these services total approximately $29 billion per year and are responsible for close to half of Medicare payments for physician services. The levels of E/M services define the wide variations in skill, effort, and time and are required for preventing and/or diagnosing and treating illness or injury, and promoting optimal health. These codes are intended to represent physician work, and because much of this work involves the amount of training, experience, expertise, and knowledge that a provider may bring to bear on a given patient presentation, the true indications of the level of this work may be difficult to recognize without some explanation. At first glance, selecting an E/M code may appear to be difficult, but the system of coding clinical visits may be mastered once the requirements for code selection are learned and used.
Types of E/M Services When approaching E/M, the first choice that a provider must make is what type of code to use. The following tables outline the E/M codes for different levels of care for: • Office or other outpatient services—new patient • Office or other outpatient services—established patient • Hospital observation services • Hospital inpatient services—initial care
CPT only © 2008 American Medical Association. All Rights Reserved.
Coding Companion for Plastics/OMS/Dermatology
Evaluation and Management
Evaluation and Management • Hospital inpatient services—subsequent care • Observation or inpatient care (including admission and discharge services) • Consultations—office or other outpatient • Consultations—inpatient The specifics of the code components that determine code selection are listed in the table and discussed in the next section. Before a level of service is decided upon, the correct type of service is identified. Office or other outpatient services are E/M services provided in the physician’s office, the outpatient area, or other ambulatory facility. Until the patient is admitted to a health care facility, he/she is considered to be an outpatient. A new patient is a patient who has not received any face-to-face professional services from the physician within the past three years. An established patient is a patient who has received face-to-face professional services from the physician within the past three years. In the case of group practices, if a physician of the same specialty has seen the patient within three years, the patient is considered established. If a physician is on call for or covering for another physician, the patient’s encounter is classified as it would have been by the physician who is not available. Thus, a locum tenens physician who sees a patient on behalf of the patient’s attending physician may not bill a new patient code unless the attending physician has not seen the patient for any problem within three years. Hospital observation services are E/M services provided to patients who are designated or admitted as “observation status” in a hospital. Codes 99218-99220 are used to indicate initial observation care. These codes include the initiation of the observation status, supervision of patient care including writing orders, and the performance of periodic reassessments. These codes are used only by the physician “admitting” the patient for observation. Codes 99234-99236 are used to indicate evaluation and management services to a patient who is admitted to and discharged from observation status or hospital inpatient on the same day. If the patient is admitted as an inpatient from observation on the same day, use the appropriate level of Initial Hospital Care (99221-99223). Code 99217 indicates discharge from observation status. It includes the final physical examination of the patient and instructions and © 2008 Ingenix
Evaluation and Management — 527
