Coding Companion for Urology/Nephrology. A comprehensive illustrated guide to coding and reimbursement

Transcription

1 Coding Companion for Urology/Nephrology A comprehensive illustrated guide to coding and reimbursement

2 Contents Getting Started with Coding Companion... i Integumentary...1 Arteries and Veins...15 Lymph Nodes...29 Abdomen...36 Kidney...53 Ureter Bladder Urethra Penis Testis Epididymis Tunica Vaginalis Scrotum Vas Deferens Spermatic Cord Seminal Vesicles Prostate Reproductive Intersex Surgery Vagina Medicine Services Appendix Evaluation and Management Index Contents

3 Nephrostomy, nephrotomy with drainage The physician creates an opening through the kidney to the exterior of the body by making an incision in the kidney. To access the kidney, the physician makes an incision in the skin of the flank, cuts the muscles, fat, and fibrous membranes (fascia) overlying the kidney, and sometimes removes a portion of the eleventh or twelfth rib. Using an incision to open the renal pelvis (pyelotomy), the physician passes a curved clamp into the renal pelvis, a middle or lower minor calyx, and the cortex of the kidney. The physician inserts a catheter tip through the same path as the clamp, and passes the tube through a stab incision in the skin of the flank. After suturing the incisions, the physician inserts a drain tube, bringing it out through a separate stab incision, and performs a layered closure. For nephrostomy, percutaneous, see or For pyelotomy with drainage (pyelostomy), see For percutaneous pyelostomy, see If the physician changes the nephrostomy tube, see For endoscopy through the nephrostomy in a later session, see ICD-9-CM Procedural Nephrotomy Nephrostomy Anesthesia ICD-9-CM Diagnostic Secondary hyperparathyroidism (of renal origin) Other specified disorders resulting from impaired renal function Acute pyelonephritis without lesion of renal medullary necrosis (Use Acute pyelonephritis with lesion of renal medullary necrosis (Use Renal and perinephric abscess (Use Pyeloureteritis cystica (Use Unspecified pyelonephritis (Use Calculus of kidney Acquired cyst of kidney Other ureteric obstruction Vesicoureteral reflux, unspecified or without reflex nephropathy Other specified disorder of kidney and ureter Hematuria, unspecified Gross hematuria Microscopic hematuria Congenital single renal cyst Congenital polycystic kidney, autosomal dominant Congenital polycystic kidney, autosomal recessive Congenital renal dysplasia Congenital medullary cystic kidney Congenital medullary sponge kidney Other specified congenital cystic kidney disease Unspecified obstructive defect of renal pelvis and ureter Congenital obstruction of ureteropelvic junction Congenital obstruction of ureterovesical junction Congenital ureterocele Other obstructive defect of renal pelvis and ureter Kidney hematoma without rupture of capsule or mention of open wound into cavity Traumatic anuria Terms To Know calculus. Abnormal, stone-like concretion of calcium, cholesterol, mineral salts, or other substances that forms in any part of the body. catheter. Flexible tube inserted into an area of the body for introducing or withdrawing fluid. congenital. Present at birth, occurring through heredity or an influence during gestation up to the moment of birth. 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. nephrostomy. Placement of a stent, tube, or catheter that forms a passage from the exterior of the body into the renal pelvis or calyx, often for drainage of urine or an abscess, for exploration, or calculus extraction. pyelonephritis. Infection of the renal pelvis and ureters that may be acute or chronic, often occurring as a result of a urinary tract infection, particularly in instances of vesicoureteric reflux, the backflow of urine from the bladder into the kidney pelvis or ureters. ureterocele. Saccular formation of the lower part of the ureter, protruding into the bladder. CCI Version , 36410, 37202, 44950, , , 50045v, 50500, 50541, , , , 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Medicare Edits Fac Non-Fac RVU RVU FUD Medicare References: None Assist N/A Kidney Kidney 55

4 Appendix 0084T 0084T Insertion of a temporary prostatic urethral stent A physician inserts a temporary urethral stent in a patient with prostatic urethral obstruction to improve voiding function. The stent system consists of a proximal balloon to prevent distal displacement, a urine port situated above to the balloon, and the stent. Topical anesthesia is administered and the physician inserts the probe to locate the external sphincter. Once the external sphincter is located, a measurement is taken and the proper size stent selected. The stent device is mounted on a single-use insertion tool and standard catheter insertion technique is used to insert it. The proximal tip, balloon, and urine port are positioned in the bladder and the balloon is inflated with 5 cc of water. The insertion device is removed. A distal anchor mechanism is secured by sutures. A retrieval suture that extends to the meatus and deflates the balloon when pulled is also secured. The stent is typically left in place for up to 90 days. 0087T 0087T Sperm evaluation, Hyaluronan sperm binding test Hyaluronan or hyaluronic acid binding (HAB) is a qualitative assay to determine sperm maturity in a fresh semen sample. Low levels of sperm binding to hyaluronan indicate that there is a low proportion of mature sperm capable of penetrating an ova and that there is a need for an intracytoplasmic sperm injection procedure (ICSI), an assisted reproductive technique. 0141T-0142T 0141T Pancreatic islet cell transplantation through portal vein, percutaneous 0142T Pancreatic islet cell transplantation through portal vein, open Islet cells are insulin-producing cell clusters found only in the pancreas. In islet cell transplants, insulin-producing islet cells are infused into the liver by portal vein embolization. Islet cell transplant is considered a less invasive alternative to pancreatic transplant. The physician uses ultrasonic guidance to insert a catheter through a skin incision in the upper abdomen and into the portal vein of the liver. Islet cells are slowly infused through the catheter. The pressure within the portal vein is monitored during the procedure to ensure that the vessel is not occluded. The catheter is removed and the incision closed. The islet cells will attach to the vessel walls in the portal vein and begin releasing insulin within a month. This procedure is limited to persons with type 1 diabetes. In an open procedure,0142t, the surgeon makes an incision in the skin overlying the liver and inserts a catheter into the portal vein. 0143T 0143T Laparoscopy, surgical, pancreatic islet cell transplantation through portal vein Islet cells are insulin-producing cell clusters found only in the pancreas. In islet cell transplants, insulin-producing islet cells are infused into the liver by portal vein embolization. Islet cell transplant is considered a less invasive alternative to pancreatic transplant. The physician places a laparoscope via a small periumbilical port or through a small incision in the right upper quadrant, and an additional port is placed in the right upper quadrant under direct vision. The physician inserts a catheter into the portal vein of the liver. Islet cells are slowly infused through the catheter. The pressure within the portal vein is monitored during the procedure to ensure that the vessel is not occluded. The catheter is removed along with the laparoscope tools, and the incision closed. The islet cells will attach to the vessel walls in the portal vein and begin releasing insulin within a month. This procedure is limited to persons with type 1 diabetes. 0193T 0193T Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence The physician uses radiofrequency energy to treat female stress urinary incontinence, the involuntary loss of urine from the urethra due to increased intra-abdominal pressure. Using a small transurethral probe, the physician applies low temperature radiofrequency energy to targeted submucosal areas of the bladder neck and urethra. This results in minute structural alterations to the collagen which, upon healing, make the tissues firmer and increase their resistance to involuntary leakage. This code is new for Radiologic examination, abdomen; single anteroposterior view Films are taken of the abdominal cavity in one view from front to back. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination Radiologic examination, abdomen; anteroposterior and additional oblique and cone views Films are taken of the abdominal cavity from front to back, with an oblique view and a focused (coned down or spot) view. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination Radiologic examination, abdomen; complete, including decubitus and/or erect views Films are taken of the abdominal cavity from front to back, back to front, or front to back with the patient lying on the side and/or standing. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest Films are taken of the abdominal cavity with the patient lying flat, standing, and/or lying on the side. This procedure includes an upright chest x-ray. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination Computed tomography, abdomen; without contrast material with contrast material(s) without contrast material, followed by contrast material(s) and further sections Computed tomography directs multiple thin beams of x-rays at the body structure being studied and uses computer imaging to produce thin cross-sectional views of various layers (or slices) of the body. It is useful for the evaluation of trauma, tumor, and foreign bodies as CT is able to visualize soft tissue as well as bones. Patients are required to remain motionless during the study and sedation may need to be administered as well as a contrast medium for image enhancement. These codes 376 Appendix

5 of less than 15 minutes. Code may be reported only by facilities. These codes are new for They replace that have been deleted Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient patients patients The qualified, nonphysician health care professional provides education and training using a standard curriculum. This training is prescribed by a physician to enable the patient to concurrently self-manage established illnesses or diseases with health care providers. Report for education and training provided for an individual patient for each 30 minutes of service. Report for a group of two to four patients and for a group of five to eight patients Hospital mandated on call service; in-hospital, each hour out-of-hospital, each hour The code reports the time for hospital mandated on call service provided by the physician. This code does not include prolonged physician attendance time for standby services or the time spent performing other reportable procedures or services. Report for each hour of hospital mandated on call service spent in the hospital and for each hour of hospital mandated on call service spent outside the hospital Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service provided during posted evening, weekend, or holiday office hours in addition to basic services Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service provided between 10 p.m. and 8 a.m. at a 24-hour facility in addition to basic services Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service provided on an emergency basis in a location other than the physician's office that disrupt other scheduled office services Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral) The home health provider visits the patient at home for care and maintenance of catheter, such as urinary catheters, and catheters placed for drainage or enteral feeding. Skilled procedures required for the home visit include Foley catheter and suprapubic catheter insertion and management; gastrostomy tube/catheter maintenance and enteral feeding; dressing changes and assessment of catheter-related wounds; management of open or draining wounds, ulcers, or fistulae and drainage tube/catheter management; related suture/staple removal; and urinary incontinence catheter management. Appendix Appendix 401