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

Transcription

1 Coing Companion for Urology/Nephrology A comprehensive illustrate guie to coing an reimbursement 2009

2 Contents Getting Starte with Coing Companion... i Integumentary...1 Arteries an Veins...15 Lymph Noes...29 Abomen...36 Kiney...53 Ureter Blaer Urethra Penis Testis Epiiymis Tunica Vaginalis Scrotum Vas Deferens Spermatic Cor Seminal Vesicles Prostate Reprouctive Intersex Surgery Vagina Meicine Services Appenix Evaluation an Management Inex Coing Companion for Urology/Nephrology Contents

3 Ureteroneocystostomy; anastomosis of single ureter to blaer anastomosis of uplicate ureter to blaer with extensive ureteral tailoring with vesico-psoas hitch or blaer flap Explanation The physician connects the lower ureter an blaer to allow for urinary rainage. The physician usually makes an incision in the skin of the abomen. After issecting the ureter at the point of isease or obstruction, the physician brings the ureter through a stab incision in the blaer an sutures the ureter to the blaer. To provie support uring healing, the physician may insert a catheter into the ureter. The physician inserts a rain tube an performs a layere uplicate ureter to the blaer. Report if this proceure is use. Report if the physician attaches a uplicate ureter to the blaer. Report if the anastomosis requires extensive urethral reconstruction. Report if the anastomosis requires suturing the blaer an psoas, or by fashioning a long, elliptical flap from the blaer. Coing Tips Note that an are unilateral proceures. If performe bilaterally, some payers require that the service be reporte twice with moifier 50 appene to the secon coe while others require ientification of the service only once with moifier 50 appene. Check with iniviual payers. Moifier 50 ientifies a proceure performe ientically on the opposite sie of the boy (mirror image). For ureteroneocystostomy combine with plastic reconstruction on the blaer an urethra (cystourethroplasty), see If the physician performs a ureteroneocystostomy to restore urethral continuity after surgical iversion, see For ureteroneocystostomy combine with partial removal of the blaer, see ICD-9-CM Proceural Ureteroneocystostomy Anesthesia ICD-9-CM Diagnostic 185 Malignant neoplasm of prostate Malignant neoplasm of trigone of urinary blaer Malignant neoplasm of blaer, part unspecifie Malignant neoplasm of ureter Seconary malignant neoplasm of retroperitoneum an peritoneum Hyronephrosis Stricture or kinking of ureter Other ureteric obstruction Vesicoureteral reflux, unspecifie or without reflex nephropathy Vesicoureteral reflux with reflux nephropathy, unilateral Vesicoureteral reflux with reflux nephropathy, bilateral Vesicoureteral reflux with reflux nephropathy, NOS Other specifie isorer of kiney an ureter Urinary tract infection, site not specifie (Use aitional coe to ientify organism, such as E. coli, 041.4) Pelvic peritoneal ahesions, female (postoperative) (postinfection) (Use aitional coe to ientify organism: 041.0, Use aitional coe to ientify any associate infertility: 628.2) Unspecifie inflammatory isease of female pelvic organs an tissues (Use aitional coe to ientify organism: 041.0, 041.1) Urinary-genital tract fistula, female Congenital obstruction of ureteropelvic junction Congenital obstruction of ureterovesical junction Congenital ureterocele Other obstructive efect of renal pelvis an ureter Other specifie congenital anomalies of ureter Ureter injury without mention of open woun into cavity Ureter injury with open woun into cavity Injury to other specifie pelvic organs with open woun into cavity Complications of transplante kiney (Use aitional coe to ientify nature of complication: 078.5, 199.2, , ) Acciental puncture or laceration uring proceure V64.41 Laparoscopic surgical proceure converte to open proceure Terms To Know anastomosis. Surgically create connection between ucts, bloo vessels, or bowel segments to allow flow from one to the other. CCI Version , 36000, 36410, 37202, 44850, 44950, , 50650, 50715, , , , 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, Also not with 50780: 50740v, 50760v, Also not with 50782: 50780v, 50785v, Also not with 50783: v, 50780v, 50782v, 50785v, Also not with 50785: v, Note: These CCI eits are use for Meicare. Other payers may reimburse on coes liste above. Meicare Eits Fac Non-Fac RVU RVU FUD Meicare References: None Assist Ureter CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for Urology/Nephrology Ureter 127

4 Reprouctive Placement of neeles or catheters into pelvic organs an/or genitalia (except prostate) for subsequent interstitial raioelement application Right kiney Aorta Blaer (may have been remove) Stoma (surface outlet) Left kiney Ureters Neeles or catheters are place in the genitalia or pelvic organs Explanation The physician places neeles or catheters into the pelvic organs an/or genitalia, excluing the prostate, for subsequent interstitial raioelement application. The raioactive isotopes that are introuce subsequently, such as ioine-125 or pallaium-103, are containe within tiny sees that are left in place to eliver raiation over a perio of months. They o not cause any harm after becoming inert. This metho provies raiation to the prescribe boy area while minimizing exposure to normal tissue. Coing Tips For placement of neeles or catheters into the prostate, see For insertion of uterine tanems an/or vaginal ovois for clinical brachytherapy, see For insertion of Heyman capsules for clinical brachytherapy, see ICD-9-CM Proceural Other laparotomy Incision of testis Other oophorotomy Hysterotomy Incision of cervix Culotomy Other vaginotomy Other incision of vulva an perineum Implantation or insertion of raioactive elements Anesthesia , ICD-9-CM Diagnostic Malignant neoplasm of specifie parts of peritoneum Malignant neoplasm of peritoneum, unspecifie Malignant neoplasm of enocervix Malignant neoplasm of exocervix Malignant neoplasm of other specifie sites of cervix Malignant neoplasm of cervix uteri, unspecifie site Malignant neoplasm of ovary (Use aitional coe to ientify any functional activity) Malignant neoplasm of other specifie sites of uterine anexa Malignant neoplasm of unescene testis (Use aitional coe to ientify any functional activity) Malignant neoplasm of other an unspecifie testis (Use aitional coe to ientify any functional activity) Seconary an unspecifie malignant neoplasm of intrapelvic lymph noes Seconary malignant neoplasm of retroperitoneum an peritoneum Seconary malignant neoplasm of ovary Seconary malignant neoplasm of other specifie sites Neoplasm of uncertain behavior of ovary (Use aitional coe to ientify any functional activity) Enlargement of lymph noes V10.43 Personal history of malignant neoplasm of ovary (Coe first any continuing functional activity: 259.2) V84.02 Genetic susceptibility to malignant neoplasm of ovary (Use aitional coe, if applicable, for any associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , V84.04 Genetic susceptibility to malignant neoplasm of enometrium (Use associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , V84.09 Genetic susceptibility to other malignant neoplasm (Use associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , Terms To Know brachytherapy. Form of raiation therapy in which raioactive pellets or sees are implante irectly into the tissue being treate to eliver their ose of raiation in a more irecte fashion. Brachytherapy provies raiation to the prescribe boy area while minimizing exposure to normal tissue. catheter. Flexible tube inserte into an area of the boy for introucing or withrawing flui. genitalia. External organs relate to reprouction. prostate. Male glan surrouning the blaer neck an urethra that secretes a substance into the seminal flui. CCI Version , 36410, 37202, , , 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, Note: These CCI eits are use for Meicare. Other payers may reimburse on coes liste above. Meicare Eits Fac Non-Fac RVU RVU FUD Meicare References: None Assist e 350 Reprouctive CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for Urology/Nephrology

5 Evaluation an Management This section provies an overview of evaluation an management (E/M) services, tables that ientify the ocumentation elements associate with each coe, an the feeral ocumentation guielines with emphasis on the 1997 exam guielines. This set of guielines represent the most complete iscussion of the elements of the currently accepte versions. The 1997 version ientifies both general multi-system physical examinations an single-system examinations, but proviers may also use the original 1995 version of the E/M guielines; both are currently supporte by the Centers for Meicare an Meicai Services (CMS) for auit purposes. Although some of the most commonly use coes by physicians of all specialties, the E/M service coes are among the least unerstoo. These coes, introuce in the 1992 CPT manual, were esigne to increase accuracy an consistency of use in the reporting of levels of non-proceural encounters. This was accomplishe by efining the E/M coes base on the egree that certain common elements are aresse or performe an reflecte in the meical ocumentation. The Office of the Inspector General (OIG) Work Plan for physicians consistently lists these coes as an area of continue investigative review. This is primarily because Meicare payments for these services total approximately $29 billion per year an are responsible for close to half of Meicare payments for physician services. The levels of E/M services efine the wie variations in skill, effort, an time an are require for preventing an/or iagnosing an treating illness or injury, an promoting optimal health. These coes are intene to represent physician work, an because much of this work involves the amount of training, experience, expertise, an knowlege that a provier may bring to bear on a given patient presentation, the true inications of the level of this work may be ifficult to recognize without some explanation. At first glance, selecting an E/M coe may appear to be ifficult, but the system of coing clinical visits may be mastere once the requirements for coe selection are learne an use. Types of E/M Services When approaching E/M, the first choice that a provier must make is what type of coe to use. The following tables outline the E/M coes for ifferent levels of care for: Office or other outpatient services new patient Office or other outpatient services establishe patient Hospital observation services Hospital inpatient services initial care Hospital inpatient services subsequent care Observation or inpatient care (incluing amission an ischarge services) Consultations office or other outpatient Consultations inpatient The specifics of the coe components that etermine coe selection are liste in the table an iscusse in the next section. Before a level of service is ecie upon, the correct type of service is ientifie. Office or other outpatient services are E/M services provie in the physician s office, the outpatient area, or other ambulatory facility. Until the patient is amitte to a health care facility, he/she is consiere to be an outpatient. A new patient is a patient who has not receive any face-to-face professional services from the physician within the past three years. An establishe patient is a patient who has receive 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 consiere establishe. If a physician is on call for or covering for another physician, the patient s encounter is classifie as it woul have been by the physician who is not available. Thus, a locum tenens physician who sees a patient on behalf of the patient s attening physician may not bill a new patient coe unless the attening physician has not seen the patient for any problem within three years. Hospital observation services are E/M services provie to patients who are esignate or amitte as observation status in a hospital. Coes are use to inicate initial observation care. These coes inclue the initiation of the observation status, supervision of patient care incluing writing orers, an the performance of perioic reassessments. These coes are use only by the physician amitting the patient for observation. Coes are use to inicate evaluation an management services to a patient who is amitte to an ischarge from observation status or hospital inpatient on the same ay. If the patient is amitte as an inpatient from observation on the same ay, use the appropriate level of Initial Hospital Care ( ). Coe inicates ischarge from observation status. It inclues the final physical examination of the patient an instructions an Evaluation an Management CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for Urology/Nephrology Evaluation an Management 403