Month: December 2018

We will dedicate our next few posts to explaining some of the more notable changes to CPT for 2019.

Some changes that may impact physicians in a variety of specialties are the revisions to the existing PICC line codes and the addition of two new combination codes to capture PICC lines placed with imaging guidance.

A PICC line is a “peripherally inserted central catheter.” These vascular lines are often inserted in patients who require chemotherapy, IV antibiotics, or supplemental nutrition. CPT states that a vascular line is a PICC line when it is inserted in a peripheral vein (e.g., basilic, cephalic, or saphenous vein) and when it terminates in a central vein (i.e., subclavian vein, brachiocephalic (innominate) veins, iliac veins, the superior or inferior vena cava, or the right atrium)..

Revised Codes

CPT 36568 and 36569 have been revised to indicate that they represent a PICC line insertion without imaging guidance.

CPT 36568 is still reported for a patient younger than 5 years old while CPT 36569 is reported for a PICC line placement in a patient 5 or older.

Codes 36568 and 36569 are reported when no imaging guidance is used to place the PICC line (meaning no guidance is used to identify and/or enter potential venous access sites and no guidance is used to confirm the final position of the PICC line).

CPT 36584 was also revised. This code is used for complete replacement of a PICC line through the same venous access. For example, if a PICC line is already in place from a right basilic access and that line is removed and replaced with a new PICC line also placed via the right basilic vein, the PICC line is replaced “through the same venous access.” CPT 36584 was revised this year to indicate that it includes replacement of a PICC line through the same venous access with imaging guidance. The imaging guidance included in this code is used both to identify potential venous access sites and to confirm the final termination point for the PICC line. If imaging guidance is used to identify the potential access site (e.g., ultrasound guidance is used to identify the basilic vein, confirm it is patent and gain access into the vein), but imaging guidance is not used to confirm the final catheter termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter termination point and that x-ray is read by a radiologist not by the surgeon placing the PICC line), report CPT 36584 with modifier 52.
We are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.

The CPT guidelines were also updated to indicate that a PICC line replacement through the same venous access without any imaging guidance, is now reported with unlisted CPT code 37799.

New Codes

CPT 36572 and 36573 are brand new codes published this year to report placement of a PICC line with imaging guidance.

Like CPT codes 36568 and 36569, these new codes are differentiated based on the age of the patient receiving the PICC line. CPT 36572 is reported for insertion of a PICC line with imaging guidance for a patient younger than 5 years old and CPT 36573 is reported for insertion of a PICC line with imaging guidance for a patient 5 or older.

The imaging guidance included in CPT codes 36572 and 36573 is imaging guidance to identify and/or enter potential venous access sites and imaging guidance to confirm the final termination point of the PICC line. As with CPT 36584, if imaging guidance is used to identify potential access sites (e.g., fluoroscopic guidance is used to identify the cephalic vein, confirm it is patent, and enter the vessel), but imaging guidance is not used to confirm the catheter’s final termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter’s final termination point, and that x-ray is read by a radiologist not by the physician placing the PICC line), report CPT code 36572 or 36573 with modifier 52. Again, we are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.

Key Guidelines:

Because CPT codes 36572, 36573, and 36584 all include imaging guidance in their descriptions, you can no longer report imaging guidance codes such as 77001 or 76937 with these codes (these codes are combination codes that include the work of placing the PICC line as well as the imaging guidance necessary to place the line). It would also not be appropriate to report imaging guidance codes such as 77001 or 76937 with 36568 or 36569 since there is now a combination code to report insertion of a PICC line with imaging guidance.

Another rule to keep in mind is that when ultrasound is used to place a PICC line, the same documentation guidelines that apply to CPT 76937 also apply to these new combination codes. Documentation for ultrasound guidance must include 1) assessing patency of the potential access site(s) with the ultrasound (and noting any obstruction of the vessel(s) where appropriate); 2) entering the vessel under real-time ultrasound visualization; and 3) permanently storing the ultrasound images.

I hope these guidelines are helpful to you as you code PICC lines in the coming year. We will continue to cover some of the key 2019 CPT updates over the next couple of weeks to keep you informed of changes that may impact your daily work.

Hemorrhoids are swollen veins located in the anus or the lower rectum. It is estimated that at least 50% of adults will develop hemorrhoids at some point in their lives. So it is no surprise that if you code for a general surgeon, you will probably code a lot of procedures designed to treat hemorrhoids.

Hemorrhoids can be treated by many different methods including excision, ligation, stapling, and destruction. It is helpful to understand what each of these terms means so you know if you are picking a CPT code that accurately describes the procedure you are trying to code.

1. Excision: Excision means to cut out/remove
2. Ligation:  Ligation means to tie off/cut off blood supply
3. Stapling: Stapling as the name implies involves placing staples that separate hemorrhoid tissues from the rest of the rectal wall while a knife is used to excise the hemorrhoids.
4. Destruction: Destruction means using some kind of thermal energy such as electrocautery, laser, or infrared to apply heat to and destroy the hemorrhoid tissue.

In addition to identifying “how” the hemorrhoid was treated, you also need to know additional details including where the hemorrhoids are located, how many hemorrhoids (e.g., groups/columns) are treated, and whether there are specific complications associated with the hemorrhoids (e.g., prolapse, thrombosis). I find it helpful to ask myself the questions below when coding hemorrhoid procedures to identify all of these important details.

Question #1: Where are the hemorrhoids located?

When you look at codes for hemorrhoid treatment in CPT, you will see the words “internal” and “external” used a lot in the code descriptions. An internal hemorrhoid is one that is above the dentate line (i.e., above the line that divides the upper two thirds from the lower third of the anal canal). The dentate line is also sometimes called the pectinate line or the anorectal junction so if you see any of these terms in an operative report and the hemorrhoids are located above this line, rest assured these terms all mean the same thing, and you know the hemorrhoid is internal. Internal hemorrhoids are often located further up in the lower rectum where they cannot be felt during an exam. An external hemorrhoid is one that is located below the dentate line. External hemorrhoids based on their location are often visible externally and can be felt when examining the area. You may also see a surgeon use the term mixed hemorrhoid which is one that begins above the dentate line and continues below it (i.e., it has an internal and external component).

Most surgeons that I have worked for are aware of the importance of documenting whether the hemorrhoids they are treating are internal, external, or both (i.e., mixed). This detail affects not only our CPT code for the procedure, but our ICD-10-CM code for the diagnosis as well. Sometimes, though, a surgeon won’t say the word “internal” but instead will list the location of the hemorrhoids in terms of “quadrants.” You may see notations such as “right posterior,” “right anterior,” and “left lateral.” The CPT manual states that an anal column is considered to be an internal hemorrhoid in 3 major areas of the anal canal: the right posterior (or 1 o’clock position); right anterior (or 5 o’clock position); or the left lateral (or 9 o’clock position). So if you see those quadrants or “clock positions” mentioned in your operative report you can be confident you are looking at an internal hemorrhoid. If the surgeon fails to provide any of these details to confirm internal vs external hemorrhoids, reach out to the surgeon to obtain additional information before coding.

Question #2: How many hemorrhoids are being treated?

You will see the words “group” or “column” listed quite frequently in CPT codes for hemorrhoid procedures. These terms refer to swelling of an anorectal vein in a single location that results in a “cluster-like” or “pillar” appearance that is known as a group/column of hemorrhoids. The group/column would be excised together by cutting around the hemorrhoid tissue. Again surgeons quite often explain how many columns/groups of hemorrhoids are present by giving a quadrant or clock position to reference the hemorrhoid’s location (e.g., “I then excised the right posterior column of hemorrhoids and then approached the right anterior location to continue my excision”). In this example, we have two groups/columns of hemorrhoids (one in the right posterior quadrant and a second in the right anterior quadrant). If the surgeon removes both groups/columns in a single surgery, this would count as removal of two groups/columns of hemorrhoids in CPT.

It is also possible for a single stand-alone hemorrhoid that is not part of a column or a group to be treated. There are some specific CPT codes for treatment of these single hemorrhoids that are by themselves and not part of a group or column of hemorrhoids. We will look at some of those codes in detail in the examples below.

Question #3: Does the surgeon provide any details about complications associated with the hemorrhoids being treated?

One common hemorrhoid complication associated with internal hemorrhoids is prolapse (where a hemorrhoid originates in an internal location but bulges outside the anal opening). This “bulging” or prolapse is sometimes intermittent. For example, it may occur during a bowel movement when the patient is straining to go to the bathroom and the bulging may later shrink on its own causing the hemorrhoid to retract back inside the anal opening. Other times a hemorrhoid will prolapse and that “bulging” outside the anal opening will become more persistent.

One common hemorrhoid complication associated with external hemorrhoids is thrombosis. In a thrombosed hemorrhoid, a blood clot forms inside the hemorrhoid causing the hemorrhoid to swell significantly. This condition can be very painful and sometimes requires an incision into the hemorrhoid to drain the clot or removal of the hemorrhoid all together. Another term you may see in reference to external hemorrhoids is an anal skin tag which is excess skin left behind after blood has drained from an external hemorrhoid.

Taking note of any complications mentioned can assist you both with coding the CPT for the procedure performed and the ICD-10-CM code for the reason the procedure was performed.

Now that we have our key questions outlined, let’s look at some examples and use this method to select the appropriate CPT code.

Example #1: After sterile prep and drape, an exam under anesthesia was performed. A rigid anoscope was inserted and mixed hemorrhoids were visualized at 1 o’clock and 5 o’clock. Beginning in the 1 o’clock position, a scalpel was used to incise the rectal mucosa freeing the right posterior hemorrhoids. Bleeding was controlled and sutures were used to close the incision. We then proceeded to the 5 o’clock location and again used a scalpel to incise the rectal mucosa freeing the right anterior hemorrhoids. Bleeding was controlled and sutures used to close the incision. Both specimens were sent to pathology. The patient left the OR in stable condition.

Answer example #1: The bolded and underlined portions of the note above are keys we need to code this procedure. First, we see the patient has mixed hemorrhoids (so the hemorrhoids have both an internal and external component). Next we see locations provided (1 o’clock which again is the right posterior quadrant per CPT and 5 o’clock which again is the right anterior quadrant per CPT). After confirming the presence of these two groups/columns of hemorrhoids, the physician “makes an incision” in the rectal lining and frees up the hemorrhoids which are then removed. He then closes the wounds with sutures. This occurs in two separate locations (1 o’clock and 5 o’clock) so we again have two columns/groups of hemorrhoids being “excised.”

The appropriate CPT code for this procedure is 46260 (excision of two or more columns or groups of internal and external hemorrhoids). The anoscope mentioned at the start of the case to visualize the hemorrhoids is CPT 46600, but if we check our NCCI edits, this code is bundled. So we will report only CPT 46260 for this procedure.

Example #2: After sterile prep and drape, we inserted an anal dilator reducing the prolapsed internal hemorrhoid. We then inserted a PPH stapler and fired two rows of staples along the redundant rectal mucosa. A circular knife was then utilized to amputate the prolapsed hemorrhoidal tissue. Bleeding was controlled and the patient left the OR in stable condition.

Answer example #2: The bolded and underlined portions of the procedure note are keys we need for coding. We first see a complication of “prolapse” and the fact that this is an internal hemorrhoid. We then see the surgeon “insert a PPH stapler” (a type of stapler used in colorectal surgery) and “fire two rows of staples” along the redundant tissue from this prolapsed hemorrhoid. After placing his staples, he uses a circular knife to cut around the tissue and amputate (or remove) the prolapsed hemorrhoid.

The appropriate code for this case is CPT 46947. This code includes removal of hemorrhoid tissue by a stapling technique (where the surgeon places rows of staples to separate the tissue that needs to be removed from the rectal wall and then removes that tissue with a knife). We also see the example of “prolapsed internal hemorrhoid” in the code description for this code which fits with our indication for procedure.

Example #3: After sterile prep and drape, an exam under anesthesia was performed and the thrombosed external hemorrhoid was visualized. We first incised this hemorrhoid to evacuate the clot and then proceeded to incise around the base of the hemorrhoid. The hemorrhoid was removed in its entirety. The incision was left open to allow for continued drainage. The patient left the OR in stable condition.

Answer example #3: The bold and underlined portions of the note are keys we need for coding. First we see the word “thrombosed” underlined which is a complication of the hemorrhoid where a blood clot has formed in the hemorrhoid. We also see the fact that this is an “external hemorrhoid.” The physician starts off by draining the external hemorrhoid (by incising into it and evacuating the clot). He then “incises around the base (bottom) of the hemorrhoid” and “removes it completely.”

If we take these two procedures together (incising into the hemorrhoid to drain the clot and then excising the external hemorrhoid), we actually get two CPT codes: 46083 for the drainage of the thrombosed hemorrhoid and 46320 for the excision. If we check our NCCI edits, though, 46083 is a column 2 (or potentially bundled) code to 46320. The reason for the edit is “standards of medical/surgical practice” which means that incising into and draining a thrombosed hemorrhoid is a routine part of the excision procedure. So unless these two procedures were performed on different hemorrhoids or at different times on the same day, we would not unbundle 46083.

CPT 46320 should be reported for this procedure.

I hope this method and the examples provided help you to simplify your hemorrhoid procedure coding!