Procedural coding errors can lead to lost revenue or unintentional upcoding at ambulatory surgery centers.
Stephanie Ellis, RN, CPC, is the president and owner of Brentwood, Tenn.-based Ellis Medical Consulting, and Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.
Here Ms. Jones and Ms. Ellis elaborate on 12 trouble areas for coding various specialties, including general surgery, GI & endoscopy, ophthalmology, otolaryngology, podiatry and urology.
General surgery
If the mesh implant causes a complication and has to be removed later, use 27087 for the removal of hernia mesh for Medicare bills. For payors other than Medicare, use the combination of 11005 with +11008 add-on, which is more specific but not covered by Medicare, she says.
2. Lipoma removals. The depth of lipoma fatty tumors varies among patient cases, so be careful with coding accuracy. If the lipoma is just under the skin and does not involve a layered closure, then use the appropriate code from 11400 to 11446, Ms. Ellis says. For lipomas removed from the subcutaneous or deeper tissue levels, including those with layered closures, use codes from the 20000 section. The size and depth of the tumor excision are crucial to correctly code these removals.
• Code 31295 – Maxillary sinus balloon dilation endoscopy
• Code 31296 – Frontal sinus balloon dilation endoscopy
• Code 31297 – Sphenoid sinus balloon dilation endoscopy
CPT guidance is to not bill the balloon sinuplasty codes with the standard sinus endoscopy codes when performed on the same sinus on the same side for the same surgical case, according to Ms. Ellis. These codes are covered by Medicare for ASCs, but many Blue Cross Blue Shield commercial plans do not cover these procedures.
"For ASCs, Medicare reimburses at a higher rate for endoscopies with the removal of tissue (codes 31267, 31276 and 31288) than they do for the balloon sinuplasty procedures," she says, "so if both procedures were performed on the same sinus on the same side, it might be more beneficial to bill for the removal of tissue procedure instead of the balloon procedure."
If a payor does not cover the balloon sinuplasty procedures, then coders have the option to bill with the regular sinus endoscopy codes based on whether or not tissue was removed and to leave the balloon codes off of the claim.
If performed, be sure to code the lavage or irrigation procedures usually performed with the balloon sinuplasty procedures using the codes:
• Code 31000 for lavage by cannulation of the maxillary sinus
• Code 31002 for lavage by cannulation of the sphenoid sinus
• There is no code for a lavage/irrigation of the frontal sinus
4. Intestinal polyps. Coders should look for tattooing of the polyps or lesions found in the intestinal tract during endoscopy, a process where surgeons highlight the lesion so it will stand out next time a surgeon looks in the intestinal tract, according to Ms. Jones. Tattooing of a lesion should be coded as 45381. Sometimes 45381 may be used for a saline lift injected into the lesion. If tattooing or saline lift is mentioned in the report, it is not simply incidental and needs to be coded.
8. Hammertoe repairs. Hammertoe repairs, which fix an abnormal joint flexion in a toe, can include any combination of fusion or arthrodesis procedure of the phalanx, excision of the proximal phalanx, capsulotomy of the phalanx and associated tendon work.
However, Ms. Ellis says, the 28285 CPT code for a hammertoe repair does not include a metatarophalangeal joint capsulotomy when it is performed in the same case on the same toe. If it is performed with the hammertoe procedure, use the code 28270-59.
9. Subtalar arthroereisis. Ms. Ellis cautions coders not to confuse a subtalar arthrodesis fusion procedure (CPT code 28725) with the subtalar arthroereisis, in which an implant is inserted into the foot. Use Healthcare Common Procedure Code S2117 for the subtalar arthroereisis procedure, or bill it with an unlisted foot CPT code 28899, she says. Use the implant code S2117 for the implant used in the podiatric procedure. Subtalar arthroereisis is not covered by all payors, including Medicare.
"For example, if the surgeon fulgurates or resects two small lesions and one large tumor, bill code 52240 [one time only]," she says. "Do not add tumor sizes together to code. Each tumor should be measured individually to determine the appropriate size category code."
She also recommends avoiding the pathology report for help coding bladder tumor cases. The pathology report will only help you determine the diagnosis for fulgurated, or destroyed, tumors.
11. Cystoscopic lesion biopsy. Often when patients have a small lesion removed for biopsy, hemostasis will be performed to control the normal bleeding that results from a lesion removal. Coders may misreport this as the destruction of a lesion. The correct code for the lesion biopsy with hemostasis is 52204, not to be confused with 52224 for biopsy with the treatment of a lesion.
12. Retrograde pyelograms. When a cystoscopy with a retrograde pyelogram is performed, use the CPT code 52005. This code is considered to be a unilateral code in the CPT book. If it is performed bilaterally, bill it for commercial payors using the -50 or -RT/-LT Modifiers, Ms. Ellis says. Modifiers are not necessary for a Medicare case, though, because Medicare will not reimburse when 52005 is billed bilaterally.
The 52005 code is also unbundled from many other urinary procedures in the CCI edits, she says, so if it is unbundled, it should not be billed. "Even when code 52005 is unbundled, usually the imaging used in the procedure is not," she says. For retrograde pyelogram procedures, the 74420-TC imaging code is also billable for the radiologic component. While not all commercial payors will reimburse for this code, Medicare will.
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Stephanie Ellis, RN, CPC, is the president and owner of Brentwood, Tenn.-based Ellis Medical Consulting, and Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.
Here Ms. Jones and Ms. Ellis elaborate on 12 trouble areas for coding various specialties, including general surgery, GI & endoscopy, ophthalmology, otolaryngology, podiatry and urology.
General surgery
1. Hernia repairs. When a hernia repair is performed at the same time that an excision of a lesion (i.e. lipoma) from the spermatic cord is performed during the same surgical case, the code 55520-59 can be billed. The code represents the excision of a lesion of the spermatic cord procedure with the -59 modifier to designate it as a separate procedure, according to Ms. Ellis. The code C1781 should be used for all ASC claims for the hernia mesh implant except when billing Medicare.
If the mesh implant causes a complication and has to be removed later, use 27087 for the removal of hernia mesh for Medicare bills. For payors other than Medicare, use the combination of 11005 with +11008 add-on, which is more specific but not covered by Medicare, she says.
2. Lipoma removals. The depth of lipoma fatty tumors varies among patient cases, so be careful with coding accuracy. If the lipoma is just under the skin and does not involve a layered closure, then use the appropriate code from 11400 to 11446, Ms. Ellis says. For lipomas removed from the subcutaneous or deeper tissue levels, including those with layered closures, use codes from the 20000 section. The size and depth of the tumor excision are crucial to correctly code these removals.
GI & Endoscopy
3. Balloon sinuplasty. Here are the most common CPT codes for balloon sinuplasty procedures:• Code 31295 – Maxillary sinus balloon dilation endoscopy
• Code 31296 – Frontal sinus balloon dilation endoscopy
• Code 31297 – Sphenoid sinus balloon dilation endoscopy
CPT guidance is to not bill the balloon sinuplasty codes with the standard sinus endoscopy codes when performed on the same sinus on the same side for the same surgical case, according to Ms. Ellis. These codes are covered by Medicare for ASCs, but many Blue Cross Blue Shield commercial plans do not cover these procedures.
"For ASCs, Medicare reimburses at a higher rate for endoscopies with the removal of tissue (codes 31267, 31276 and 31288) than they do for the balloon sinuplasty procedures," she says, "so if both procedures were performed on the same sinus on the same side, it might be more beneficial to bill for the removal of tissue procedure instead of the balloon procedure."
If a payor does not cover the balloon sinuplasty procedures, then coders have the option to bill with the regular sinus endoscopy codes based on whether or not tissue was removed and to leave the balloon codes off of the claim.
If performed, be sure to code the lavage or irrigation procedures usually performed with the balloon sinuplasty procedures using the codes:
• Code 31000 for lavage by cannulation of the maxillary sinus
• Code 31002 for lavage by cannulation of the sphenoid sinus
• There is no code for a lavage/irrigation of the frontal sinus
4. Intestinal polyps. Coders should look for tattooing of the polyps or lesions found in the intestinal tract during endoscopy, a process where surgeons highlight the lesion so it will stand out next time a surgeon looks in the intestinal tract, according to Ms. Jones. Tattooing of a lesion should be coded as 45381. Sometimes 45381 may be used for a saline lift injected into the lesion. If tattooing or saline lift is mentioned in the report, it is not simply incidental and needs to be coded.
Ophthalmology
5. Photocoagulation in the eye. If a patient has a retinal tear or lattice degeneration, sometimes surgeons will photocoagulate the retina to prevent further degeneration and detachment. However, coders often misinterpret this technique as treating a detached retina, Ms. Jones says. Use the code 67145 for prophylactic photocoagulation. Patients may have other eye issues at the same time, but a prophylactic treatment of the retina can be coded separately.Otolaryngology
6. Tympanoplasty. For a tympanoplasty, follow the American Medical Association guidelines for reporting, including separate reporting for the temporalis fascia graft. If it is harvested through a separate incision, than the graft should be coded as 15732, Ms. Jones says. Sometimes physicians do not clearly indicate if a separate incision was used for the graft, so clarify for the chance at additional allotted reimbursement.Podiatry
7. Bunion removal. Coders should be cautious of coding an Austin/Akin bunion procedure, in which metatarsal and phalangeal incisions are made in the toe. It can be coded as a 28299 double osteotomy, rather than coding Austin (28296) and Akin (28298) separately, Ms. Jones says. If coders do not understand the double technique, then they can inadvertently upcode the procedure.8. Hammertoe repairs. Hammertoe repairs, which fix an abnormal joint flexion in a toe, can include any combination of fusion or arthrodesis procedure of the phalanx, excision of the proximal phalanx, capsulotomy of the phalanx and associated tendon work.
However, Ms. Ellis says, the 28285 CPT code for a hammertoe repair does not include a metatarophalangeal joint capsulotomy when it is performed in the same case on the same toe. If it is performed with the hammertoe procedure, use the code 28270-59.
9. Subtalar arthroereisis. Ms. Ellis cautions coders not to confuse a subtalar arthrodesis fusion procedure (CPT code 28725) with the subtalar arthroereisis, in which an implant is inserted into the foot. Use Healthcare Common Procedure Code S2117 for the subtalar arthroereisis procedure, or bill it with an unlisted foot CPT code 28899, she says. Use the implant code S2117 for the implant used in the podiatric procedure. Subtalar arthroereisis is not covered by all payors, including Medicare.
Urology
10. Bladder tumors. A physician must have detailed documentation to correctly code a bladder tumor procedure because of the special coding guidelines, Ms. Ellis says. Only one bladder tumor code is billable per case, and the code for the size or area of the largest lesion removed or fulgurated should be billed, no matter how many tumors are part of the case."For example, if the surgeon fulgurates or resects two small lesions and one large tumor, bill code 52240 [one time only]," she says. "Do not add tumor sizes together to code. Each tumor should be measured individually to determine the appropriate size category code."
She also recommends avoiding the pathology report for help coding bladder tumor cases. The pathology report will only help you determine the diagnosis for fulgurated, or destroyed, tumors.
11. Cystoscopic lesion biopsy. Often when patients have a small lesion removed for biopsy, hemostasis will be performed to control the normal bleeding that results from a lesion removal. Coders may misreport this as the destruction of a lesion. The correct code for the lesion biopsy with hemostasis is 52204, not to be confused with 52224 for biopsy with the treatment of a lesion.
12. Retrograde pyelograms. When a cystoscopy with a retrograde pyelogram is performed, use the CPT code 52005. This code is considered to be a unilateral code in the CPT book. If it is performed bilaterally, bill it for commercial payors using the -50 or -RT/-LT Modifiers, Ms. Ellis says. Modifiers are not necessary for a Medicare case, though, because Medicare will not reimburse when 52005 is billed bilaterally.
The 52005 code is also unbundled from many other urinary procedures in the CCI edits, she says, so if it is unbundled, it should not be billed. "Even when code 52005 is unbundled, usually the imaging used in the procedure is not," she says. For retrograde pyelogram procedures, the 74420-TC imaging code is also billable for the radiologic component. While not all commercial payors will reimburse for this code, Medicare will.
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