Knowledge Base Category -

Question

Has Palmetto GBA finalized its coverage determination for Cardiac Resynchronization Therapy (CRT)?

Answer

Yes. The coverage determination became effective December 12, 2021 and can be found in Palmetto GBAs’ Local Coverage Article A58821 (link) and Palmetto GBAs’ Local Coverage Determination L39080 (link).

As with most of the other Medicare coverage guidelines, CRT has specific diagnosis codes that must be submitted on the claim to support medical necessity. In addition, the medical record must have documentation of the patient’s QRS duration - reflected in milliseconds - from the EKG, as well as documentation of QRS morphology such as right / left bundle branch block. Check the LCA and LCD for complete coverage requirements.

Did You Know?

The advice from Coding Clinic has changed regarding Anxiety with Depression.

Coding Clinic, 1st Quarter 2021, page 10 advises that Anxiety with Depression should be coded as two separate conditions, unless the physician has documented a link between the two. We are not to assume the linkage. If documentation does link the two conditions together, then F41.8, Other Specified Anxiety Disorders should be assigned.

Please note that this advice has been updated from Coding Clinic, 3rd Quarter 2011, page 6, which previously instructed us to code Anxiety with Depression as one condition.

Why It Matters?

It is important to correctly capture the clinical picture of the admission by coding the correct ICD-10 codes. Also, the Depression codes have been recently revised.

What Can I Do?

Review both Coding Clinics and the Oct. 1, 2021, coding changes with the coding staff.

Question

If a provider has documented diabetes and arthritis, can we code it to diabetes with arthropathy (E11.618)?

Diabetes, diabetic (mellitus) (sugar) (E11.9)

with

arthropathyNEC(E11.618)

Answer

No. Even though the ICD-10 Alphabetic Index has an entry for ‘Diabetes with Arthropathy NEC’, the provider needs to document the relationship between the two conditions; we cannot assume a causal relationship when a diabetic complication is “NEC”.

The “with” guideline does not apply to “not elsewhere classified (NEC)” conditions indexed to broad categories. The specific condition must be linked by the terms “with”, “due to” or “associated with”.

Arthropathy is a general term for any condition that affects the joints. There are many different types of arthropathic conditions that may not be due to diabetes. To link diabetes and arthritis, the provider needs to document the condition as a diabetic complication.

Please be aware of all diabetic NEC complications listed in the Alphabetic Index:

• Arthropathy NEC
• Circulatory complication NEC
• Complication, specified NEC
• Kidney complications NEC
• Neurologic complication NEC
• Oral complication NEC
• Skin complication NEC
• Skin ulcer NEC

References:

• ICD-10-PCS Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Pages 100-101
• Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Page 6

Question:

How do we bill mammography services when a beneficiary undergoes a screening and diagnostic mammogram on the same day?

Answer:

According to the MLN educational tool: Medicare Preventive Services (https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#MAMMO), “if you perform and bill a screening mammogram and a diagnostic mammogram on the same day, use modifier -GG to show a screening mammography turned into a diagnostic mammography.”

Question

We do ultrasound guided prostate biopsies in Radiology and report the ultrasound guidance with CPT code 76742. To report CPT code 76942, should we maintain permanently recorded images?

Answer

Yes, per the parenthetical guidelines in the Diagnostic Ultrasound section of the CPT book, permanently recorded images must be maintained for ultrasound guidance. The physician should also document the use of ultrasound guidance. This documentation can be included in the biopsy report or can be documented as a separate report. Typically, we see only one physician’s report that describes both the prostate needle biopsy as well as the ultrasound guidance.

Did You Know?

When a patient has bi-level positive airway pressure (BiPap) delivered through an endotracheal tube (ETT), the procedure code is different that BiPap (5A09x57), and the case groups to a different DRG.

Why It Matters

When BiPap is delivered through an ETT or tracheostomy, the PCS alpha index sends us to see Performance, Respiratory (5A19###).

Alphabetic Index:

BiPAP – see Assistance, Respiratory 5A09

Via

Endotracheal Tube or Tracheostomy –see Performance, Respiratory

Example: If a patient has a principal diagnosis of pneumonia, unspecified (J18.9), with a secondary diagnosis of acute respiratory failure with hypoxia (J96.01), and the patient is placed on Bipap without an ETT, the case groups to DRG 193 (Simple pneumonia and pleurisy with MCC) with a relative weight of 1.3107.

However, if this same patient is placed on BiPap, via an ETT or tracheostomy, the case groups to DRG 208 (Respiratory system diagnosis with ventilator support) with a relative weight of 2.5423.

Accurate coding of BiPap, via an ETT or tracheostomy, will not only group to a higher-weighted DRG, realizing more appropriate reimbursement, but it will also help to support the resources your facility spends on a patient. p>

What Should I Do?

Thoroughly review the record:

• Watch for words like “intubation” or “successfully intubated”
• Review any procedure reports
• Review all respiratory sheets
• Review nursing notes

References:

• ICD-10-PCS Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, 2014, page 3

Question

I am a new chargemaster (CDM) coordinator at my facility, and my current to-do list involves trying to verify the CPT / HCPCS code assignment for vaccines. How can I determine if the CPT codes assigned in the CDM for pneumonia and influenza vaccines are correct?

Answer

Don’t try to figure it out on your own – you really need the expertise of one of your hospital pharmacists to help you with this. Fortunately, there are only 2 CPT codes to choose from for the pneumonia vaccines, but 20 CPT codes and 6 HCPCS Q codes to choose from for the influenza vaccines. In our experience with pharmacy CDM reviews, hospital pharmacists are usually able to easily tell you which CPT or HCPCS code should be used.

Did You Know?

It is common for a surgeon to perform a fusion on the anterior column and the posterior column of the spine through a single incision.

Why It Matters

The codes for anterior and posterior spinal column fusion will group to the higher-weighted DRG group (453-455). You could be under-coding and losing out on thousands of dollars of reimbursement for your facility.

What Can I Do?

First, make sure you are familiar with the anatomy and the terms describing the anterior and posterior columns.

The anterior column consists of:

• Anterior longitudinal ligament
• Vertebral body
• Intervertebral Disc
• Annulus Fibrosus
• Posterior Longitudinal Ligament

The posterior column consists of:

• Pedicles
• Transverse Process (gutter)
• Lamina
• Facets
• Spinous Process

The anterior column fusion is usually what is described first in the Operative Report and is often coded correctly. However, the posterior fusion is typically overlooked and not reported. One of the reasons may be the unfamiliarity with the terms describing the posterior column. For example, a surgeon may document that bone graft was placed in the “gutters”. Gutters is another term to describe the Transverse Process, so bone graft placed in the gutters is a posterior spinal fusion.

Based on the above information, there should be a code for fusion of the anterior column and a code for the posterior column in order for the claim to group to the appropriate higher-weighted DRG.

Did you know?

Previously, there were only three ICD-10-CM codes to identify personal history of carcinoma in-situ. These sites only included the breast, cervix uteri, and other site. Effective October 1, 2019, six new codes were created for personal history of in-situ neoplasms (Z86.002 – Z86.007). Two of these sites are listed below:

• Melanoma (Z86.006) (Personal history of melanoma in-situ)
• Skin (Z86.007) (Personal history on in-situ neoplasm of skin)

Why Should I Care?

ICD-10-CM codes are used for numerous occasions, i.e., accurate payments, quality management, data statistics, public health reporting, etc. The more accurate and specific codes are reported, the more accurate and specific data outcomes will be.

What Should I Do?

Report the new codes, if the documentation describes more specific sites, to allow for more specific coding and reporting of personal history of carcinoma in-situ sites.

Question

Is it appropriate for hospitals to code and submit an outpatient surgery claim before the pathology report is available? At our hospital we do a lot of skin excisions, but we code the record and bill the claim before we have the pathology report. Therefore, there are times when the malignant skin cancers are not reported on the claim since we do not know about it at the time of coding.

Answer

Yes, it is appropriate / allowed for hospitals to code and submit a claim before the pathology report is available to the coder for review. It is up to the individual hospital to determine this process. For additional discussion, refer to Coding Clinic, 1st quarter 2017, page 15.