Coding for Spinal Procedures

Transcription

1 Coding for Spinal Procedures Audio Seminar/Webinar October 22, 2009 Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.

2 Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. CPT five digit codes, nomenclature, and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: (1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; (2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and (3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. The faculty has reported no vested interests or disclosures regarding this presentation. AHIMA 2009 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois i

3 Faculty Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Shelley C. Safian is an associate professor of medical billing and coding for Herzing University Online. Ms. Safian has published four books on coding, and a fifth book on HIM compliance. She has been a member of AHIMA for many years, and sits on the Clinical Terminology and Classification Practice Council. Ms. Safian is presently working on her PhD in Health Services Administration. AHIMA 2009 Audio Seminar Series ii

4 Table of Contents Disclaimer... i Faculty... ii Objectives... 1 Points of Discussion... 1 Anatomy of the Spine The Vertebral Column... 2 Scarum & Coccyx... 3 Vertebrae... 3 Intervertebral Discs... 4 Spinal Muscles... 4 Spinal Cord and Nerves... 5 Case Study... 5 Polling Question # Conditions of the Spine Conditions of the Spine... 7 Congenital Conditions... 7 Pathological Conditions... 8 Traumatic Injuries... 8 Iatrogenic Conditions... 9 Acute and Chronic Pain... 9 Polling Question # Radiologic Spinal Procedures Imaging Procedures Diagnostic Testing Myelography Contrast Injections X-ray, CT Scans, MRI X-ray of Spine Magnetic Resonance Imaging Nuclear Medicine Case Study Polling Question # Musculoskeletal Spinal Procedures Musculoskeletal Procedures Osteotomy Arthrodesis Arthrodesis for Deformities Fracture/Dislocation Repair Open Treatment Fracture/Dislocation Repair Closed Treatments AHIMA 2009 Audio Seminar Series (CONTINUED)

5 Table of Contents Re-Reduction Vertebroplasty Kyphoplasty Radiological Supervision Intradiscal Electrothermal Therapy (IDET) Intradiscal Therapy (Non-Electrothermal) Spinal Instrumentation Spinal Fusion Arthroplasty (Artificial Disc) Neurospinal Procedures Concurrent Radiological Services Catheter-based Treatments Lumbar Puncture (Spinal Tap) Injections Intrathecal & Epidural Device Implantation Drug Fusion Pump Implantation Insertion of Device Laminectomy Spondylolisthesis Laminectomy Laminotomy Spinal Neurostimulators Analysis and Programming Spinal Stereotactic Radiosurgery Therapeutic (Non-Surgical) Spinal Procedures Range of Motion (ROM) Testing Electromyograhy (EMG) Physical Therapy Modalities & Therapeutic Procedures Acupuntcure Osteopathic Manipulative Treatment (OMT) Chiropractic Manipulative Treatment (CMT) Polling Question # Resource/Reference List Audience Questions Audio Seminar Discussion Become an AHIMA Member Today! Audio Seminar Information Online Upcoming Audio Seminars Thank You/Evaluation Form and CE Certificate (Web Address) AHIMA 2009 Audio Seminar Series (CONTINUED)

6 Table of Contents Appendix Resource/Reference List CE Certificate Instructions AHIMA 2009 Audio Seminar Series

7 Objectives Review the ICD-9-CM coding classification and guidelines to report spinal diagnoses Discuss documentation requirements to report accurate spinal ICD-9-CM diagnosis and inpatient procedures Discuss challenging coding cases related to inpatient spinal procedures consistent with ICD-9-CM coding guidelines 1 Points Of Discussion 1: Anatomy of the Spine 2: Conditions of the Spine 3: Radiologic Spinal Procedures 4: Musculoskeletal Spinal Procedures 5: NeuroSpinal Procedures 6: Therapeutic Spinal Procedures 2 AHIMA 2009 Audio Seminar Series 1

8 The Vertebral Column Cervical C1 C7 Thoracic T1 T12 Lumbar L1 L5 Sacral S1 S5 Coccyx 4 AHIMA 2009 Audio Seminar Series 2

9 Sacrum & Coccyx 5 Vertebrae 6 AHIMA 2009 Audio Seminar Series 3

10 Intervertebral Discs 7 Spinal Muscles 8 AHIMA 2009 Audio Seminar Series 4

11 Spinal Cord and Nerves 9 Case Study Former Vice President Dick Cheney had surgery on September 17, 2009 to relieve lumbar spinal stenosis. The procedure removes a portion of the vertebra to ease pressure on the spinal cord. 10 AHIMA 2009 Audio Seminar Series 5

12 Polling Question #1 The portion of the vertebra removed to relieve the pressure is? *1 Vertebral body *2 Superior articular process *3 Lamina 11 Conditions of the Spine 12 AHIMA 2009 Audio Seminar Series 6

13 Conditions of the Spine Congenital Conditions Pathologic Conditions Traumatic Injuries Iatrogenic Conditions 13 Congenital Conditions For example: Iniencephaly 741.Xx Spina Bifida Hydromyelia Deformity of spine (lordosis, scoliosis) 14 AHIMA 2009 Audio Seminar Series 7

14 Pathological Conditions Intraspinal abscess Other myelopathy Myelopathy NOS, cord compression Ankylosing spondylitis 737.xx Curvature of spine (acquired) Congenital musculoskeletal deformities of spine 15 Traumatic Injuries Fractures 805.xx or 806.xx Dislocations 839.xx Sprains & strains 847.x Spinal cord injury Late effects + E codes 16 AHIMA 2009 Audio Seminar Series 8

15 Iatrogenic Conditions 737.xx Complications of surgical and medical care Mechanical complication of nervous system device 996.4x Mechanical complication of internal orthopedic device 17 Acute and Chronic Pain 338.1x Acute pain Acute pain due to trauma Other acute post-op pain 338.2x Chronic pain Chronic paid due to trauma Other chronic post-op pain 18 AHIMA 2009 Audio Seminar Series 9

16 Polling Question #2 Little Frankie, 2 days old, has been diagnosed with congenital postural lordosis. This is reported with diagnosis code? * * * Radiologic Spinal Procedures 20 AHIMA 2009 Audio Seminar Series 10

17 Imaging Procedures Bone Density Tests Myelography MRI, X-ray, CT Scans Nuclear Medicine 21 Diagnostic Testing Bone mineral density Bone density Diagnostic ultrasound Diagnostic ultrasound Discography & Discography 22 AHIMA 2009 Audio Seminar Series 11

18 Myelography X-ray of Spine, contrast myelogram Myelography, cervical Myelography, thoracic Myelography, lumbosacral Myelography, two + regions 23 Contrast Injections Injection, contrast material for myelogram Cisternal or lateral cervical (C1- C2) puncture, with injection of medication or other substance for diagnosis or treatment Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa) 24 AHIMA 2009 Audio Seminar Series 12

19 X-ray, CT Scans, MRI X-ray Computed Tomography (CT) Magnetic Resonance Imaging (MRI) X-ray of Spine 88.3 Skeletal series (whole skeleton) 87.2x X-ray of Spine Other x-ray of cervical spine Other x-ray of thoracic spine Other x-ray of lumbosacral spine Other x-ray of spine NOS 26 AHIMA 2009 Audio Seminar Series 13

20 Magnetic Resonance Imaging MRI of spinal canal MRI of musculoskeletal Imaging, magnetic resonance, specified site, NEC 27 Nuclear Medicine Bone and/or joint imaging Positron Emission Tomography (PET) Single Photon Emission Tomography (SPECT) 78320, 78803, AHIMA 2009 Audio Seminar Series 14

21 Nuclear Medicine Bone scan (PET) Total body scan Scan, radioisotope, specified site, NEC 29 Case Study The patient has been running a fever and has had swelling, heat, and tenderness of his back ever since he was struck by a framing stud at the construction site where he works. The physician is concerned that he may have osteomyelitis. He orders an MRI of the thoracic spine with and without contrast, which is the best imaging for detecting spinal infections. 30 AHIMA 2009 Audio Seminar Series 15

22 Polling Question #3 The MRI of the thoracic spine with and without contrast is reported with code? * * * Musculoskeletal Spinal Procedures 32 AHIMA 2009 Audio Seminar Series 16

23 Musculoskeletal Procedures Osteotomy Arthrodesis Fracture and Dislocation Repair Vertebroplasty Vertebral Augmentation Spinal Instrumentation 33 Osteotomy Osteotomy of spine, thoracic lumbar each add l cervical thoracic lumbar each add l Osteotomy, vertebrae Osteotomy, vertebrae, wedge 34 AHIMA 2009 Audio Seminar Series 17

24 Arthrodesis Arthrodesis (Surgical immobilization of a joint) x Arthrodesis, spinal or 81.3x Refusion of spine Number of vertebrae fused 35 Arthrodesis for Deformities Repair, spina bifida NEC, spinal meninges NOS, vertebral arch defect Arthrodesis, for spinal deformity 36 AHIMA 2009 Audio Seminar Series 18

25 Fracture/Dislocation Repair Type of manipulation Type of stabilization 37 Fracture/Dislocation Repair Open treatment CPT defines open treatment as either: Surgically opened, the fracture visualized, and internal fixation applied The fractured site is not opened, but the fractured bone is opened remotely 38 AHIMA 2009 Audio Seminar Series 19

26 Open Treatment Repair of vertebral fracture Open treatment and/or reduction of odontoid fracture(s) without grafting with grafting Open treatment and/or reduction of vertebral fracture(s) lumbar cervical thoracic 39 Fracture/Dislocation Repair Closed treatment CPT defines closed treatment of a fracture Means the fracture is not opened and visualized With or without manipulation With or without traction 40 AHIMA 2009 Audio Seminar Series 20

27 Closed Treatments of vertebral process fracture(s) of vertebral body fracture(s), without manipulation vertebral fracture(s) and/or dislocation(s) 41 Re-Reduction When the fracture or dislocation must be reduced again Modifier 76 when the same physician 77 when by another physician As appropriate Modifier 62 is permitted 42 AHIMA 2009 Audio Seminar Series 21

28 Vertebroplasty 43 Vertebroplasty Percutaneous vertebroplasty Percutaneous vertebroplasty thoracic lumbar each additional vertebral body 44 AHIMA 2009 Audio Seminar Series 22

29 Kyphoplasty 45 Kyphoplasty Percutaneous vertebral augmentation Includes kyphoplasty, skyphoplasty and spineoplasty Percutaneous vertebral augmentation thoracic lumbar each additional vertebral body 46 AHIMA 2009 Audio Seminar Series 23

30 Radiological Supervision Computer assisted surgery with CT/CTA Computer assisted surgery with fluoroscopy under fluoroscopic guidance under CT guidance 47 Intradiscal Electrothermal Therapy (IDET) Other destruction of disc (IDET) Percutaneous intradiscal electrothermal annuloplasty single level one or more additional levels 48 AHIMA 2009 Audio Seminar Series 24

31 Intradiscal Therapy (Non-Electrothermal) Percutaneous repair of the anulus fibrosus Percutaneous intradiscal annuloplasty 0062T single level T one or more additional levels 49 Spinal Instrumentation 84.8x Dynamic spinal stabilization device Segmental instrumentation Fixation at each end of the construct and at least one additional interposed bony attachment Non-segmental instrumentation Fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments 50 AHIMA 2009 Audio Seminar Series 25

32 Spinal Fusion 51 Arthroplasty (Artificial Disc) Replacement of Spinal Disc 84.6x Insertion of spinal disc prosthesis Total disc arthroplasty (artificial disc) cervical lumbar 52 AHIMA 2009 Audio Seminar Series 26

33 Neurospinal Procedures 53 Concurrent Radiological Services Epidurography Fluroscopic guidance Note: already includes Computer- Assisted Surgery (CAS) w/fluoroscopy 54 AHIMA 2009 Audio Seminar Series 27

34 Catheter-based Treatments 03.6 Lysis of adhesions of spinal cord and nerve roots Insertion of catheter into spinal canal Percutaneous lysis of epidural adhesions or more days day Endoscopic lysis 0027T 55 Lumbar Puncture (Spinal Tap) Spinal puncture Lumbar diagnostic Therapeutic Spinal tap Not used for the injection of dye for myelogram 56 AHIMA 2009 Audio Seminar Series 28

35 Injections Subarachnoid Epidural (cervical or thoracic) Epidural (lumbar, sacral, caudal) 03.8 Destructive agent 03.9x Other substances Contrast dyes 57 Intrathecal & Epidural Device Implantation 58 AHIMA 2009 Audio Seminar Series 29

36 Drug Infusion Pump Implantation Insertion of totally implantable infusion pump + Any associated catheterization (03.90) Implantation, revision or reposition Implantation or replacement Insertion of Device 84.8x Non-fusion stabilization device Surgical decompression Interbody spinal fusion device x Spinal fusion or x Refusion of spine 60 AHIMA 2009 Audio Seminar Series 30

37 Laminectomy 61 Laminectomy Laminectomy for exploration, decompression Laminectomy with excision of other intraspinal lesion (tumor) Rhizotomy Laminectomy with excision of herniated intervertebral disc (nucleus pulposus) 62 AHIMA 2009 Audio Seminar Series 31

38 Laminectomy Laminectomy with exploration Without facetectomy, foraminotomy, or discetomy 1 or 2 vertebral segments cervical thoracic lumbar (except for spondylolisthesis) sacral 63 Laminectomy Laminectomy with exploration Without facetectomy, foraminotomy, or discetomy More than 2 vertebral segments cervical thoracic lumbar 64 AHIMA 2009 Audio Seminar Series 32

39 Spondylolisthesis Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 65 Laminectomy With facetectomy and foraminotomy Single vertebral segment vercial thoracic lumbar each additional segment 66 AHIMA 2009 Audio Seminar Series 33

40 Laminotomy 67 Laminotomy Laminotomy (hemilaminectomy) one interspace, cervical one interspace, lumbar each additional With reexploration, single interspace cervial each additional cervical lumbar each additional lumbar 68 AHIMA 2009 Audio Seminar Series 34

41 Spinal Neurostimulators Implantation or replacement of spinal neurostimulator lead(s) x Insertion of neurostimulator pulse generator 69 Spinal Neurostimulators Percutaneous implantation of neurostimulator electrode array, epdiural Laminectomy for implantation of neurostimulator electrodes, palate/paddle, epidural 70 AHIMA 2009 Audio Seminar Series 35

42 Spinal Neurostimulators Revisions & Replacements Revision or removal of spinal neurostimulator Insertion or replacement of spinal neurostimulator pulse generator ore receive Revision or removal of implanted neurostimulator 71 Analysis and Programming A simple neurostimulator pulse generator/transmitter is one capable of affecting three or fewer of the following: Pulse amplitude Pulse duration Pulse frequency Eight or more electrode contacts Cycling Stimulation train duration Train spacing Number of programs Number of channels Alternating electrode polarities Dose time More than one clinical feature 72 AHIMA 2009 Audio Seminar Series 36

43 Analysis and Programming "A complex neurostimulator pulse generator/transmitter is one capable of affecting more than three of the below. Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral neurostimulator, without reprogramming simple spinal cord, or peripheral neurostimulator, with intraoperative or subsequent programming complex spinal cord, or peripheral neurostimulator, with intraoperative or subsequent programming, first hour each additional 30 minutes after first hour 73 Spinal Stereotactic Radiosurgery 92.3x Stereotactic radiosurgery spinal lesion each add. 74 AHIMA 2009 Audio Seminar Series 37

44 Therapeutic (Non-Surgical) Spinal Procedures 75 Range of Motion (ROM) Testing Range of motion testing Range of motion measurements and report; each extremity (excluding hand) or each trunk section (spine) 76 AHIMA 2009 Audio Seminar Series 38

45 Electromyography (EMG) Electromyography Needle electromyography Physical Therapy Mobilization of spine Ambulation and gait training Stretching of muscle or tendon Spinal traction with skull device Cotrel s traction 78 AHIMA 2009 Audio Seminar Series 39

46 Physical Therapy Physical Therapy Evaluation Re-evaluation Occupational Therapy Evaluation Re-evaluation Athletic Training Evaluation Re-evaluation 79 Modalities & Therapeutic Procedures Supervised Modalities Constant Attendance Therapeutic Procedures Note: Therapeutic procedures, group Most codes are Modifier 51 exempt 80 AHIMA 2009 Audio Seminar Series 40

47 Acupuncture Acupuncture for anesthesia Other acupuncture Acupuncture with smoldering moxa, moxibustion 81 Acupuncture without electrical stimulation, initial 15 minutes without electrical stimulation, each addl 15 minutes with re-insertion of needle(s) with electrical stimulation, initial 15 minutes with electrical stimulation, each add 15 minutes with re-insertion of needle(s) 82 AHIMA 2009 Audio Seminar Series 41

48 Osteopathic Manipulative Treatment (OMT) for general mobilization using high-velocity, lowamplitude forces using low-velocity, highamplitude forces isotonic, isometric forces using indirect forces to move tissue fluids 83 Osteopathic Manipulative Treatment (OMT) Manipulation, osteopathic one to two body regions involved to 4 body regions involved to 6 body regions involved to 8 body regions involved to 10 body regions involved 84 AHIMA 2009 Audio Seminar Series 42

49 Chiropractic Manipulative Treatment (CMT) spinal, one to two regions spinal, three to four regions spinal, five regions extraspinal, one or more regions 85 Polling Question #4 The patient was diagnosed with neoplasm of the spinal meninges. The physician performed a laminectomy and excised an intraspinal tumor. Report this with? *1 03.4, * * AHIMA 2009 Audio Seminar Series 43

50 Resource/Reference List Anatomy Guide: Normal Spine htm Medical Encyclopedia Posterior Spinal Anatomy Anatomy: The Spinal Column Treatments/Anatomy/Default.aspx 87 Audience Questions AHIMA 2009 Audio Seminar Series 44

51 Audio Seminar Discussion Following today s live seminar Available to AHIMA members at Click on Communities of Practice (CoP) icon on top right AHIMA Member ID number and password required for members only Join the Coding Community from your Personal Page under Community Discussions, choose the Audio Seminar Forum You will be able to: Discuss seminar topics Network with other AHIMA members Enhance your learning experience Become an AHIMA Member Today! To learn more about becoming a member of AHIMA, please visit our website at ahima.org/membership to Join Now! AHIMA 2009 Audio Seminar Series 45

52 AHIMA Audio Seminars Visit our Web site for information on the 2009 seminar schedule. While online, you can also register for seminars or order CDs, pre-recorded Webcasts, and *MP3s of past seminars. *Select audio seminars only Upcoming Seminars/Webinars Physician Practice E/M Guidelines November 10, 2009 Coding Clinic Update November 19, Procedure and Service Code Update December 3 & 8, 2009 AHIMA 2009 Audio Seminar Series 46

53 Thank you for joining us today! Remember sign on to the AHIMA Audio Seminars Web site to complete your evaluation form and receive your CE Certificate online at: Each person seeking CE credit must complete the sign-in form and evaluation in order to view and print their CE certificate Certificates will be awarded for AHIMA Continuing Education Credit AHIMA 2009 Audio Seminar Series 47

54 Appendix Resource/Reference List CE Certificate Instructions AHIMA 2009 Audio Seminar Series 48

55 Appendix Resource/Reference List AHIMA 2009 Audio Seminar Series 49

56 To receive your CE Certificate Please go to the AHIMA Web site click on the link to Sign In and Complete Online Evaluation listed for this seminar. You will be automatically linked to the CE certificate for this seminar after completing the evaluation. Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information after the seminar, in order to view and print the CE certificate.