00 A G EN Prelim .fm Page 1 W ednesday,N ovem ber19,2008 9:58 A M
Coding Companion for
General Surgery/
Gastroenterology
A comprehensive illustrated guide to coding and reimbursement
2009
00 A G EN TO C.fm Page i W ednesday,N ovem ber19,2008 9:59 A M
Contents
Getting Started with Coding Companion ............................. i
Skin ..................................................................................... 1
Pilonidal Cyst..................................................................... 21
Introduction ...................................................................... 22
Repair................................................................................ 26
Destruction ....................................................................... 59
Breast ................................................................................ 62
General Musculoskeletal .................................................... 83
Neck.................................................................................. 91
Back .................................................................................. 94
Spine................................................................................. 96
Abdomen/Musculoskeletal.................................................97
Humerus ........................................................................... 98
Forearm/Wrist.................................................................. 101
Hands/Fingers ................................................................. 104
Pelvis/Hip ........................................................................ 105
Femur/Knee..................................................................... 108
Leg/Ankle ........................................................................ 110
Foot/Toes ........................................................................ 113
Endoscopy....................................................................... 114
Respiratory ...................................................................... 115
Arteries and Veins ............................................................ 122
Spleen ............................................................................. 174
Lymph Nodes.................................................................. 177
Diaphragm ...................................................................... 196
Esophagus....................................................................... 203
Stomach.......................................................................... 272
Intestines......................................................................... 309
Meckel’s Diverticulum ..................................................... 390
Appendix ........................................................................ 393
Rectum ........................................................................... 397
Anus................................................................................ 462
Liver ................................................................................ 507
Biliary Tract ..................................................................... 524
Pancreas.......................................................................... 548
Abdomen/Digestive ........................................................ 568
Testis ............................................................................... 629
Tunica Vaginalis ............................................................... 633
Vas Deferens.................................................................... 636
Spermatic Cord/Seminal Vesicles ..................................... 638
Reproductive ................................................................... 643
Vagina............................................................................. 644
Thyroid ........................................................................... 645
Parathyroid ..................................................................... 656
Extracranial Nerves.......................................................... 661
Medicine ......................................................................... 665
Appendix ........................................................................ 678
Evaluation and Management........................................... 713
Index............................................................................... 735
© 2008 Ingenix
Coding Companion for General Surgery/Gastroenterology
Contents
38700
38700 Suprahyoid lymphadenectomy
141.9 Malignant neoplasm of tongue,
unspecified site
142.1 Malignant neoplasm of
submandibular gland
142.2 Malignant neoplasm of sublingual
gland
142.9 Malignant neoplasm of salivary gland,
unspecified
143.9 Malignant neoplasm of gum,
unspecified site
144.9 Malignant neoplasm of floor of
mouth, part unspecified
145.0 Malignant neoplasm of cheek mucosa
145.9 Malignant neoplasm of mouth,
unspecified site
146.9 Malignant neoplasm of oropharynx,
unspecified site
148.9 Malignant neoplasm of hypopharynx,
unspecified site
160.9 Malignant neoplasm of site of nasal
cavities, middle ear, and accessory
sinus, unspecified site
161.0 Malignant neoplasm of glottis
The physician makes a curved incision
beginning below the ear curving down to the
top of the hyoid bone and continuing toward
the chin. The tissues are dissected and the
targeted structures are exposed. The
submental and submandibular lymph nodes
are removed along with the submandibular
gland and surrounding tissues. The incision is
sutured with drain if necessary.
This is a unilateral procedure. If performed
bilaterally, some payers require that the service
be reported twice with modifier 50 appended
to the second code while others require
identification of the service only once with
modifier 50 appended. Check with individual
payers. Modifier 50 identifies a procedure
performed identically on the opposite side of
the body (mirror image). For cervical
lymphadenectomy, see 38720. For cervical
lymphadenectomy (modified radical neck
dissection), see 38724.
172.9 Melanoma of skin, site unspecified
196.0 Secondary and unspecified malignant
neoplasm of lymph nodes of head,
face, and neck
200.01 Reticulosarcoma of lymph nodes of
head, face, and neck
200.11 Lymphosarcoma of lymph nodes of
head, face, and neck
200.21 Burkitt's tumor or lymphoma of lymph
nodes of head, face, and neck
238.8 Neoplasm of uncertain behavior of
other specified sites
ICD-9-CM Procedural
Terms To Know
Coding Tips
40.3
Regional lymph node excision
Anesthesia
malignant neoplasm. Any cancerous
tumor or lesion exhibiting uncontrolled tissue
growth that can progressively invade other
parts of the body with its disease-generating
cells.
melanoma. Highly metastatic malignant
neoplasm composed of melanocytes that
occur most often on the skin from a
preexisting mole or nevus but may also occur
in the mouth, esophagus, anal canal, or
vagina.
secondary. Second in order of occurrence
or importance, or appearing during the course
of another disease or condition.
unilateral. Located on or affecting one side.
CCI Version 14.3
12001-12007, 12020-12047, 13100-13101,
13131-13132, 36000, 36410, 37202, 38500,
42440, 51701-51703, 62318-62319,
64415-64417, 64450, 64470, 64475, 69990,
90760, 90765, 90772, 90774, 90775
Note: These CCI edits are used for Medicare.
Other payers may reimburse on codes listed
above.
Medicare Edits
Fac Non-Fac
RVU
RVU
FUD
20.03 20.03
90
38700
Medicare References: None
Assist
d
bilateral. Consisting of or affecting two sides.
38700 00320
closure. Repairing an incision or wound by
suture or other means.
ICD-9-CM Diagnostic
dissection. Separating by cutting tissue or
body structures apart.
140.8 Malignant neoplasm of other sites of
lip
lymphadenectomy. Dissection of lymph
nodes free from the vessels and removal for
examination by frozen section in a separate
procedure to detect early-stage metastases.
drain. Device that creates a channel to allow
fluid from a cavity, wound, or infected area
to exit the body.
CPT only © 2008 American Medical Association. All Rights Reserved.
Coding Companion for General Surgery/Gastroenterology
© 2008 Ingenix
Lymph Nodes — 185
Lymph Nodes
Explanation
161.1 Malignant neoplasm of supraglottis
161.3 Malignant neoplasm of laryngeal
cartilages
161.8 Malignant neoplasm of other specified
sites of larynx
161.9 Malignant neoplasm of larynx,
unspecified site
170.0 Malignant neoplasm of bones of skull
and face, except mandible
170.1 Malignant neoplasm of mandible
incision. Act of cutting into tissue or an
organ.
49570-49572
49570 Repair epigastric hernia (eg, preperitoneal
fat); reducible (separate procedure)
49572
incarcerated or strangulated
ICD-9-CM Procedural
53.59 Repair of other hernia of anterior
abdominal wall
53.69 Other and open repair of other hernia
of anterior abdominal wall with graft
or prosthesis
Anesthesia
00750
ICD-9-CM Diagnostic
551.29 Other ventral hernia with gangrene
552.29 Other ventral hernia with obstruction
553.29 Other ventral hernia without mention
of obstruction or gangrene
789.06 Abdominal pain, epigastric
Terms To Know
absorbable sutures. Strands prepared from
collagen or a synthetic polymer and capable
of being absorbed by tissue over time.
epigastric hernia. Protrusion of a section
of the intestine, omentum, or other structure
through a fascial defect opening in the
abdominal wall just above the umbilicus.
Explanation
Coding Tips
Hernia repairs are defined by age (younger
than 6 months, 6 months to 5 years, age 5
years and older), type (inguinal, femoral,
incisional, ventral, epigastric, umbilical,
spigelian), whether the hernia has been
previously repaired (initial, recurrent), and
clinical presentation (reducible, incarcerated,
strangulated, sliding). Note that 49570 is a
separate procedure by definition and is usually
a component of a more complex service and
is not identified separately. When performed
alone or with other unrelated
procedures/services it may be reported. If
performed alone, list the code; if performed
with other procedures/services, list the code
and append modifier 59.
reducible hernia. Protrusion of tissue
through the wall of another structure that can
be manually returned to the correct
anatomical position.
buried suture. Continuous or interrupted
suture placed under the skin for a layered
closure.
continuous suture. Running stitch with
tension evenly distributed across a single
strand to provide a leakproof closure line.
interrupted suture. Series of single stitches
with tension isolated at each stitch, in which
all stitches are not affected if one becomes
loose, and the isolated sutures cannot act as
a wick to transport an infection.
purse-string suture. Continuous suture
placed around a tubular structure and
tightened, to reduce or close the lumen.
retention suture. Secondary stitching that
bridges the primary suture, providing support
for the primary repair; a plastic or rubber
bolster may be placed over the primary repair
and under the retention sutures.
CCI Version 14.3
15830, 36000, 36410, 37202, 43752, 44005,
44180, 44950, 49250-49255, 51701-51703,
62318-62319, 64415-64417, 64450, 64470,
64475, 69990, 90760, 90765, 90772, 90774,
90775
Also not with 49570: 49000, 49010, 49568
Also not with 49572: 44820-44850,
49000-49010, 49568-49570
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
d
10.09 10.09
90
49570
d
12.48 12.48
90
49572
Medicare References: 100-2,15,260;
100-4,12,30; 100-4,12,90.3; 100-4,14,10
strangulated. Constricted and congested
area, typically in an intestine, caused by
herniation that results in compromised blood
supply to that area.
CPT only © 2008 American Medical Association. All Rights Reserved.
Coding Companion for General Surgery/Gastroenterology
© 2008 Ingenix
Abdomen/Digestive — 617
Abdomen/Digestive
The physician repairs an epigastric hernia. The
physician makes an incision over the hernia.
The hernia sac is identified and dissected from
surrounding structures. The fascial defect is
identified circumferentially. The hernia is
reduced and the hernia sac may be resected.
In 49572, the physician repairs an incarcerated
epigastric hernia. The hernia sac is opened
and the contents of the sac are examined. If
the hernia contents are viable, the hernia is
reduced and the sac ligated and resected. The
hernia defect is closed with sutures. The
incision is closed.
nonabsorbable sutures. Strands of natural
or synthetic material that resist absorption into
living tissue and are removed once healing is
under way. Nonabsorbable sutures are
commonly used to close skin wounds and
repair tendons or collagenous tissue. Examples
include surgical silk, surgical cotton, linen,
stainless steel, surgical nylon, polyester fiber,
polybutester (Novofil), polyethylene
(Dermalene), and polypropylene (Prolene,
Surilene).
suture. Numerous stitching techniques
employed in wound closure.
04 A G EN EM .fm Page 713 W ednesday,N ovem ber19,2008 10:00 A M
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 General Surgery/Gastroenterology
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 — 713