Procedure Based Coding

Procedure Based Coding

Jon K. Hathaway

Objectives

Review Global definition

Review common modifiers

first reported in the literature in what

year?

CPT 4

Identifies procedures performed.

Assigns a “work value” to each

procedure also known as an “RVU” or “relative value unit”.

CPT-4

Let’s jump in…

Definition

Global Package

 Includes Pre-Op H&P done the day before

or day of surgery.

 Does not include the pre-op visit one week

before to finalize counseling and confirm plan.

 Includes certain pre-operative tasks.

 Includes certain operative tasks.

 Includes certain post-operative tasks.

○ Hospital

○ Office

 Sometimes includes other procedures.

Global Packages

 Minor

 Pre-Op: Same day visits

 Intra-Op: Procedure, supplies, anesthesia

 Post-Op:

0 day global procedures

10 day global procedures

 Does not include any visits, related or not, outside the global period.

 Major

 Pre-Op: All visits beginning one day before the surgery, including the hospital admission work-up.

 Intra-Op: Procedure and any surgeon administered anesthesia.

 Post-Op: Post-op visits related to the procedure up to 90 days after the service

 Does not include the E/M service in which the decision was made to perform the surgery, diagnostic tests/procedures, stabilization prior

57454

Colposcopy of the Cervix (including

adjacent/upper vagina), with biopsy of cervix AND ECC.

Pre-Op: Positioning, prepping and draping

and catheter placement.

Intra-Op: Speculum, enhancing medium,

exam, biopsy, ECC, hemostasis, local.

Post-Op: Dressing/Packing,

evaluation/stabilization, dictation, review of pathology, completion of patient record, instructions to patient, consultation with family.

Additional included procedures: Suturing

or cautery of biopsy site

57454

Does not include:

Destruction of vulvar lesions

Vulvar colposcopy

Destruction of vaginal lesions

57454

RVU:

Hospital—3.71 Office—4.19

Global period: 0 days

Assistant: Not covered.

Co-surgeon: Not covered.

What if….

You didn’t do biopsy and/or ECC?

Separate codes for colpo only, colpo

with ECC (no biopsy), colpo with biopsy (no ECC).

A patient is seen in the office for

colposcopy due to an abnormal

pap done at her family doctor’s

office. Correct billing is:

 Colp osco py w it...  Offic e visi t a...  Offic e visi t a...  Cons ulta tion  a... 0% 0% 0% 0% 1. Colposcopy with or without biopsy/ECC

2. Office visit and colposcopy on the following day. 3. Office visit and colposcopy

with or without biopsy/ECC 4. Consultation and

colposcopy with or without biopsy/ECC

Three modifiers to remember

22: Unusual and increased services.

25: Procedure and E&M on the same

day.

Visit + Procedure

F.S. is a 23 yo G0 who presents to

the ER c/o RLQ tenderness. ER physician performs and exam and determines she needs a CT scan to evaluate the appendix. CT shows no appy but +fluid in abdomen c/w blood, recommend clinical

correlation.

In the meantime, F.S.’s pregnancy

test comes back positive.

You are paged and

perform/document a Hx and PE deemed worthy of a Est. Pt. level 4 visit. During this exam, it is

determined that the patient requires a trip to the OR for dx laparoscopy, possible ectopic.

Dx L/S shows R ectopic pregnancy

which was removed laparoscopically by salpingectomy and the patient was discharged home after an

uneventful PACU stay and stable VS.

What should you bill?

1 2 3 4 5 0% 0% 0% 0% 0% 1.Dx L/S, L/S salpingectomy 2.Dx L/S, L/S salpingectomy + outpatient office visit

3.L/S treatment of ectopic

4.L/S treatment of ectopic + outpatient office visit

5.L/S treatment of ectopic + inpatient office visit.

What should you bill/code?

Should you get paid for your

services in the ER?

99214

What procedures were performed?

Dx Laparoscopy (49320-8.33

RVU)

L/S salpingectomy (58661-17.48

RVU)

Exam under anesthesia

However…

59151: L/S tx of ectopic with

salpingectomy/oophorectomy

Includes Dx L/S 20.51 RVUs

Why does this one pay so much

Final Bill

99214-57 (Level 4 visit that resulted in

the decision to perform major surgery.)

59151 L/S tx of ectopic with excision.

Use modifier -25 (E&M plus a minor procedure) in the ER or office when you make a decision to perform a EMBx, word catheter placement or I&D.

Can also use this code in the office when

you make a decision to perform an IUD placement.

All of the following were

treatments for menorrhagia

except?

the armpits and groin.

2. Intravaginal liquid pitch

3. Eating bread made

from black rye.

4. Intravaginal burnt

cork

5. Cupping applied to

Mrs. Smith

53 y.o. postmenopausal woman who

presents c/o postmenopausal bleeding. Was sent to you by her PCP.

What next?

Mrs. Smith

Consultation with appropriate

documentation of a new patient/consultation level 3.

Decide to perform an EMB.

EMB attempted, but os was too

What should you bill?

1.

Level 3 E&M

2.

Endometrial bx

3.

-25 modifier

4.

-53 modifier

(abandoned

procedure).

Billing Mrs. Smith

Add a -25 modifier to the consult.

Provided an E & M visit that resulted in the need to perform a minor procedure.

Some providers will schedule on separate days.

Add a -53 modifier to the procedure.

Abandoned procedure.

Mrs. Johnson

27 yo G1P0 seen in the office for

prenatal care. Found to have

elevated BP so was sent to triage for evaluation.

Was seen in triage, labs done

(normal) and sent home with a 24 hour urine protein.

Mrs. Johnson’s Bill

Two visits vs. One visit

One visit

Bill the E & M code that fits the service provided (including any tests/ultrasounds).

Mrs. Johnson (part 2)

Mrs. Johnson seen for routine OB care.

Later that day, Mrs. Johnson is in a car

accident and admitted for 4 hour observation.

Bill for routine OB visit AND bill for the

E & M code because there is a separate ICD-9 diagnosis (use modifier 59).

Mrs. Lopez

C/S was performed at 8 AM.

Pt had a PPH at 2 PM.

Despite your best efforts, a

hysterectomy was required and performed at 5 PM.

Mrs. Lopez’s bill

Bill for the C/S

Bill for the hysterectomy (which

includes an exploratory laparotomy) with modifier -78 (return to OR for complication within the global period).

If planned C/S+hyst then use the

hysterectomy at time of C/S add on code.

A patient presents to the ER for

evaluation and sent home. The

correct code set to use is:

ient i... ... 0% 0% 0% 0% 1. Outpatient 2. Inpatient Admit 3. Inpatient Observation 4. Emergency Room

Gyn is called in to evaluate an

ovarian cyst on exlap. An

oophorectomy is performed. They

should bill:

1. Assistant surgeon on the exploratory laparotomy. 2. Consultation code and

surgeon for any procedure performed.

3. Consultation code based on time only—no

procedure.

4. Primary surgeon on

oophorectomy—cannot bill consultation because she is asleep and cannot get ROS.

Gyn Oncology is called in to assist on a

hysterectomy. They should bill:

 Assis tant  surg ...  Con sultat ion  c...  Cons ulta tion  c...  Prim ary  surge o... 0% 0% 0% 0%

1. Assistant surgeon on the hysterectomy.

2. Consultation code and surgeon for any procedure performed.

3. Consultation code based on time only—no

procedure.

4. Primary surgeon on hysterectomy.

HELP

Sources:

Essential guide to Coding in OB/GYN OB/GYN Coding Manual

FAQ for OB/GYN

CPT-4 and ICD-9 books/online

Coding courses

The End

Inpatient Coding

 Admission care:  Subsequent care:  Discharge care:

 Admission/Discharge same day care:  Observation care:

Admission Care

History Exam Decision Time RVU

(Work/Total) 99221 Detailed or

Comprehensive Detailed orComprehensive Straightforwardor Low 30 _min. 1.92/2.64

99222 Comprehensive Comprehensive Moderate 50

min. 2.61/3.58

99223 Comprehensive Comprehensive High 70

min. 3.86/5.26

99221: 21 yo at 9 weeks admitted for hyperemesis gravidarum. 99222: 23 yo admitted with PID. (ACOG book)

99223: 16 yo at 32 weeks with severe HTN, thrombocytopenia and headache.

Subsequent Hospital Care

(Need 2 of 3 or time)

History Exam Decision Time RVU (Work/Tot al)

99231

Problem-focused Problem-focused

Straightforward/

Low 15 _min. 0.76/1.06

99232 Expanded PF Expanded PF Moderate 25

min.

1.39/1.91

99233 Detailed Detailed High 35

min. 2.00/2.74 99231: 33 yo admitted for pelvic pain who is responding to medication and

observation.

Discharge Care

(From inpatient)

RVU (Work/Total) 99238 30 minutes or less 1.28/1.88

99239 More than 30 minutes 1.90/2.74

Includes: Exam, discussion of hospital stay and postdischarge care 

guidelines, instructions for continuing care to all relevant caregivers, 

preparation of discharge records, prescriptions and referral forms.

Admission & Discharge Same Day

History Exam Decision RVU (Work/To tal) 99234 Detailed/

Comprehensive Detailed/Comprehensive Straightforward/_Low 2.56/3.59

99235 Comprehensive Comprehensive Moderate 3.41/4.71 99236 Comprehensive Comprehensive High 4.26/5.84

Medicare requires inpatient/observation care for at least 8 hours.  If less than 

Observation Care

History Exam Decision RVU

(Work/Total)

99218 Detailed/

Comprehensive Detailed/Comprehensive Straightforward/Low 1.28/1.77

99219 Comprehensive Comprehensive Moderate 2.14/2.93

99220 Comprehensive Comprehensive High 2.99/4.10

99217 Discharge care on separate date. 1.28/1.88

These are used for patients who are being observed to see if they warrant 

admission, transfer or discharge.

Inpatient Consultation

History Exam Decision Time RVU

(work/total)

99251 Problem-focused Problem-focused Straightforward _{20 min 1.00/1.37}

99252 Expanded PF Expanded PF Straightforward _{40 min 1.50/2.11}

99253 Detailed Detailed Low _{55 min 2.27/3.22}

99254 Comprehensive Comprehensive Moderate _{80 min 3.29/4.65}

99255 Comprehensive Comprehensive High ₁₁₀

min 4.00/5.62 Medicare does NOT pay for any consultation, inpatient or outpatient.

A patient is admitted before midnight.

She is seen by the attending the next

day and discharged home. What code

should the attending use?

 Initi al ob ser v...  Admi ssio n and  ...  Only  disch arge. ..  Initi al ob serv ... 0% 0% 0% 0%

1. Initial observation care on day of admission and discharge care on the day of discharge.

2. Admission and discharge on same day.

3. Only discharge services on day of discharge.

4. Initial observation care on day of discharge.

Examples of A&D codes

Physician A admits her patient to

observation at 10AM for

gastroenteritis and dehydration at 22 weeks gestation. At 5:30PM she is re-evaluated by the on-call

physician and discharged home.

Medicare: Observation codes only.

in a serious car accident and returns to the

hospital with contractions. She is admitted for 24 hour observation. To bill correctly, you should:

 Chang e th e pr i...  Bill fo r the  a...  Bill fo r the  d...  Bill  for bo th ... 0% 0% 0% 0%

1. Change the prior

discharge and just bill for continuing care.

2. Bill for the admission, but not the discharge.

3. Bill for the discharge but not the

admission.

4. Bill for both an admission and a discharge.

The next morning she is

discharged home. You should bill:

... ... .. u...

0% 0% 0% 0%

1. Discharge from observation code.

2. Discharge from inpatient care.

3. Bill an A&D code because the admit and discharge were less than 24 hours apart.