Author: Kimberly Mansingh

Article

Antibiotic Spacer Removal Followed by Total Hip (CPT 27132 or 27134)?

Kimberly Mansingh

Q. A patient had a total hip arthroplasty last year, but due to infection, the prior total hip (both acetabular and femoral components) had to be removed. In their place, the surgeon inserted a static antibiotic spacer. The patient now presents four months later after the infection resolved and is ready for a new total hip. How are the removal of the antibiotic spacer and the insertion of the new total hip (again both acetabular and femoral components) coded?

A. Assign CPT 27132: Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft. This code will include the removal of the spacer, the insertion of a new total hip (both acetabular and femoral components), and any bone grafting that may be necessary (note that bone grafting is not required but it is included when performed).

Coding Tips: While you may be tempted to code CPT 27134: Revision of a total hip arthroplasty, both components, with or without autograft or allograft instead since the patient had a total hip arthroplasty in the past, it’s important to note that this code represents removal of a total hip with insertion of a new total hip during the same operative session. In a case where the patient already had the original total hip removed in an earlier surgery and was left with a static antibiotic spacer, code 27134 would not be accurate since there are no total hip components to remove.

Articulating vs. Static Spacers: It’s also important to understand that antibiotic spacers can be static or articulating. Static spacers such as the one featured in the question above are inserted to resolve infection after the infected joint prosthesis is removed and provide no mobility for the joint. Articulating spacers on the other hand are specialized antibiotic spacers that contain a femoral stem and a modular head that allows for some mobility of the hip while the infection is resolving. Articulating spacers reduce the risk of joint contracture because of immobility in the joint and may be used for patients who have a prolonged infection that must be resolved before the new total hip can be inserted.

In an operative report that describes removal of an articulating spacer followed by insertion of a new total hip, you might see language that reads “we then turned our attention to the femoral stem” or “the femoral component was then removed.” This can be confusing because a permanent hip prosthesis also has a femoral component (sometimes referred to as a femoral stem). Seeing this language may lead a coder to conclude that the patient still had one of the permanent components from the original total hip in place and create confusion around whether to code 27132 or perhaps 27134 or even 27138. With that said, we would not expect to see a patient with a component of a permanent hip prosthesis and an antibiotic spacer at the same time so that referral to a “femoral stem” or a “femoral component” is generally just part of an articulating spacer (which is a temporary implant not a permanent prosthesis).

Coding Caveat? Until this year, the guidance for coding removal of a static or an articulating spacer followed by insertion of a new total hip has been the same: report CPT 27132. At the AMA Symposium in late 2019, though, the American Academy of Orthopedic Surgery (AAOS) outlined some new proposed guidance for coding this type of two-stage joint replacement when an articulating spacer is involved. Instead of recommending 27132 for removal of the articulating spacer followed by insertion of a new total hip, the AAOS suggested reporting 27134 instead because the work of removing an articulating spacer is similar to that of removing the original permanent hip prosthesis. While I certainly agree with that thought, I have not seen new guidance from the AMA or CMS supporting this new recommendation just yet. Typically, once authoritative guidance from these agencies is published, insurance carriers will align with the new guidance, making it easier to get your claims paid following the new rules. So for now, I continue to use the 27132 following the historical guidance (adding modifier 22 for increased complexity associated with removal of an articulating spacer when supported by the documentation). I am also keeping an eye out for any references from these agencies that aligns with the AAOS recommendation to report CPT 27134 for a surgery where an articulating spacer is removed and a new total hip is inserted and will update this article once such guidance is received. In the interim, I would encourage you to discuss this surgery with your top payers and your internal team at your organization to ensure accurate and optimal coding.

References: CPT Assistant, December 1, 2008, copyright American Medical Association

International Journal of Medical Sciences, copyright Ivyspring International Publisher (source for overview of static vs. articulating spacers) Static vs. Articulating Spacers

Article

Partial Colectomy vs. Partial Colectomy with Ileocolostomy

Kimberly Mansingh

Q. Can you explain the difference between CPT codes 44140 and 44160? Both codes represent a partial colectomy, and I am unclear on what work must be performed after the colectomy to choose between the two codes.

A. These two codes often generate confusion for surgical coders. The confusion usually stems from uncertainty about what the term “ileocolostomy” which appears in the description of CPT 44160 means and what part of the bowel is removed in each procedure. Before we break down the definitions of both codes, if you are a visual learner and want a refresher on the anatomy of the colon, check out this image: Segments of the Colon Explained

  • CPT 44140 includes a partial colectomy with an anastomosis (reconnection) of two ends of remaining colon in the body. The anastomosis created during this procedure is a “colo-colonic” (or colon to colon anastomosis). For example, if a laparotomy incision is made and part of the ascending colon and the transverse colon are removed followed by an anastomosis between the remaining ends of the ascending and transverse colon, CPT 44140 should be coded. The same would be true for an open approach with partial removal of any part of the colon followed by anastomosis of the remaining two ends of the colon (e.g., removal of the descending colon with anastomosis between the sigmoid and the transverse colon, removal of the transverse colon and ascending colon with anastomosis of the cecum and the descending colon, etc.).
  • CPT 44160 on the other hand represents excision of part of the colon and excision of the terminal ileum (the end of the last segment of the small intestine) followed by an ileocolostomy. The term ileocolostomy is often confusing because, in other colectomy codes where we see a term ending in “-ostomy” (colostomy, ileostomy, etc.), the “ostomy” refers to bringing the remaining end of the colon up to an opening created in the abdominal wall. A bag is then attached and feces leave the body through that artificial opening. At its most basic level, though, the suffix “-ostomy” simply means to “create an opening” or to “create a new connection.” So the term ileocolostomy means “to create a new connection between the ileum and the colon.” When we look at the description of CPT 44160 with this new understanding, the procedure represented by this code becomes clearer. To code CPT 44160, the documentation must support 1) removal of part of the colon, 2) removal of the terminal ileum, and 3) an anastomosis (new connection) between the remaining ileum and the remaining colon. For example, if a laparotomy incision is made, the terminal ileum and cecum are removed, and the ascending colon and the remaining ileum are anastomosed, CPT 44160 should be coded. Again this code is appropriate when any part of the colon and terminal ileum are removed through an open approach and an ileocolonic anastomosis (aka an ileocolostomy) is created (e.g., the terminal ileum, cecum, ascending, and part of the transverse colon are all removed and the remaining transverse colon and ileum are anastomosed).

For those of you coding laparoscopic colectomies, the same explanation provided above for CPT 44140 and 44160 also applies to CPT codes 44204 and 44205 in the laparoscopic world. CPT 44204 is for a laparoscopic approach with removal of part of the colon and a colocolonic anastomosis while CPT 44205 is for a laparoscopic approach with removal of part of the colon and the terminal ileum followed by an ileocolostomy.

Understanding the terminology in the code descriptions as well as the anatomy of the colon and the small intestine are keys to coding surgeries these surgeries accurately.

Article

Accurately Coding Novel Coronavirus (COVID-19)

Kimberly Mansingh

**Updated with new information as of 8/2/2020**

As our understanding of the COVID-19 virus continues to evolve from a clinical perspective, the coding guidance issued by the AHA continues to evolve as well. Changes to the previous guidance provided are in bold and captions with the text **Updated 8/2/2020** to help you spot the new guidelines and get the information you need quickly. AHIMA also has an updated article showing the latest AHA guidance with many different clinical scenarios addressed so I will link you to this great resource as well: https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ .

While ICD-10-CM is not the usual focus of content we provide, the novel coronavirus (COVID-19) continues to impact healthcare professionals and facilities across the globe and is impacting daily life for  many of us as well. With all the preparations going on and interruptions to daily life, one impact we may not have considered is the impact this new virus will have for us in our daily coding.

The CDC recently published interim guidelines for coding ICD-10-CM related to the treatment of patients who test positive for COVID-19 and for those who have had a known or suspected exposure and require further testing and workup. While the ICD-10-CM codes for COVID-19 might not be top of mind right now, ensuring that positive cases of COVID-19 and suspected exposure and testing are captured accurately from a coding perspective will ultimately help organizations who track and trend statistics in global health events understand the full impact of this new virus. So with that in mind, we want to dedicate today’s article to the proper coding of COVID-19  from an ICD-10-CM perspective, and provide a few case examples that might help those of you coding services for the treatment of patients impacted by the virus.

ICD-10-CM Codes for Novel Coronavirus (COVID-19):

  • For DOS through 3/31/2020: For patients with a confirmed diagnosis of COVID-19 undergoing treatment of conditions related to COVID-19, you will report first the code for the condition being treated (e.g., J80 for acute respiratory distress syndrome) followed by code B97.29: Other coronavirus as the cause of disease classified elsewhere.
  • For DOS on or after 4/1/2020: For patients with a confirmed diagnosis of COVID-19 undergoing treatment of conditions related to COVID-19, you will report first the code U07.1: COVID-19 followed by any codes for the condition(s) being treated (e.g., J80 for acute respiratory distress syndrome).
  • For patients with confirmed exposure to COVID-19 (e.g., a relative who is positive for the virus) who are undergoing further testing and workup to confirm if they too have COVID-19, report ICD-10-CM code Z20.828: Contact with and (suspected) exposure to other viral communicable diseases.
  • For patients with concern about exposure to COVID-19 that is ruled out after further workup, you can report ICD-10-CM code Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out.

Coding Tips for Novel Coronavirus (COVID-19):

  • It is really important that we only code B97.29 or U07.1 once the patient has a definitive diagnosis of COVID-19. If the documentation indicates that COVID-19 is “suspected,” “probable,” or uses other similar terms of uncertainty, code the signs/symptoms the patient is being treated for (e.g., fever, shortness of breath, etc.) plus Z20.828 for exposure to COVID-19 if that exposure is supported by the documentation. **Updated 8/2/2020: It is important to note that a physician can clinically confirm that a patient has COVID-19 in their medical records even if the test results are still pending. A physician can also deem that a patient is positive for COVID-19 even if their test is ultimately negative. If a physician diagnosed a patient with COVID-19 while the test results were pending and the test is ultimately negative, though, the physician should be queried to ensure the diagnosis of COVID-19 is still appropriate. If the physician confirms the diagnosis, you may code U07.1 per the latest guidance from AHA.**
  • The documentation must support the link between COVID-19 and the condition being treated (e.g., viral pneumonia due to COVID-19) to code the ICD-10-CM code for the condition being treated along with B97.29 or the primary diagnosis U07.1. There is not a presumed cause and effect relationship between respiratory conditions and COVID-19. While patients with more severe cases of COVID-19 are likely to have respiratory conditions as a result, there are many other conditions and organisms (e.g., bacteria) unrelated to COVID-19 that may cause respiratory conditions as well. If documentation is unclear, please query the physician or other qualified healthcare professional. Accurate coding is really important in these cases. **Updated 8/2/2020: Per the AHA, the physician does not need to link the COVID-19 explicitly as the cause of a respiratory condition to code U07.1. The positive test result or the physician’s clinical statement that the patient has COVID-19 is sufficient to code both the U07.1 and the respiratory condition documented.**
  • Notice that B97.29 is a code for “cause of disease classified elsewhere.” This means that B97.29 is not a principal or primary diagnosis but instead would be reported secondary to the code for the condition being treated. In contrast, the new code U07.1 which is effective for DOS on or after 4/1/2020 may be reported as a primary ICD-10-CM code.
  • **Updated 8/2/2020: Since we are now several months into this pandemic, we are starting to see patients with a history of COVID-19. This history may be important to document and code because the history of COVID may effect patient treatment. Per the AHA, a history of COVID-19 should be coded with Z86.19. If the patient is seen in follow up for a history of COVID-19, you can code both Z09 (follow up) and Z86.19 (for the history of COVID-19) to explain the reason for the encounter. Otherwise, Z86.19 may be used as an additional diagnosis with the primary diagnosis explaining reason for care (e.g., patient presents for surgery for CAD and the physician documents they have a history of COVID-19 but are now asymptomatic and testing negative – you could code I25.10 followed by Z86.19). **
  • **Updated 8/2/2020: Finally, we also have some patients with sequela of the disease. Again as we learn more about COVID-19, reports of patients who have been deemed “long-haulers” who are having sequela effects from COVID infection weeks or months prior have emerged. Per the AHA, if a patient presents for treatment of a sequela of COVID-19, code first the condition being treated followed by code B94.8 to capture the sequela COVID-19. While B94.8 is not unique to COVID-19, since COVID-19 is an infectious disease, and we have direct guidance from AHA to use this code for COVID-19 sequelas, adding B94.8 is appropriate.**

Case Examples- Novel Coronavirus (COVID-19):

Example #1: A 56-year-old woman presents to the hospital with a three day history of dry cough, low-grade fever, and respiratory distress. The patient is admitted by the emergency department physician and ultimately tests positive for novel coronavirus . A pulmonologist is then consulted. After obtaining a chest x-ray, the pulmonologist diagnoses the patient with viral pneumonia related to COVID-19 and recommends a treatment plan to the physician who requested the consult. The visit is a level 4 consult. What is the coding for the pulmonologist?

Answer Example #1: CPT code is 99254 (for a level 4 inpatient consult for non-Medicare payers that accept consult codes or 99222 for Medicare or other payers that no longer allow consults). For a DOS on or prior to 3/31/2020, the ICD-10-CM codes for the pulmonologist will be J12.89 (other viral pneumonia) and B97.29 (other coronavirus as the cause of disease classified elsewhere). For a DOS on or after 4/1/2020, the ICD-10-CM codes for the pulmonologist will be U07.1 (COVID-19) and J12.89 (other viral pneumonia). While the patient presents with signs/symptoms, she now has a definitive diagnosis of novel cornavirus (i.e., COVID-19) and was diagnosed during the encounter as having viral pneumonia related to the COVID-19. Because the cause and effect between the viral pneumonia and the COVID-19 is documented, it is appropriate to code the viral pneumonia first followed by the code for COVID-19.

Example #2: A 70-year-old man has been admitted to the hospital for the past 5 days. The admitting physician has already diagnosed him with acute respiratory distress syndrome (ARDS) due to COVID-19, and his respiratory distress continues to worsen. The hospital intensivist performs emergent intubation to support his lungs. No other care other than the intubation is provided by the intensivist. What is the appropriate coding for this scenario?

Answer Example #2: CPT code 31500 would be reported for the emergent intubation. For a DOS on or prior to 3/31/2020, the ICD-10-CM codes for the intensivist will be J80 (acute respiratory distress syndrome) and B97.29 (other coronavirus as the cause of disease classified elsewhere). For a DOS on or after 4/1/2020, the ICD-10-CM codes for the intensivist will be U07.1 (COVID-19) and J80 (acute respiratory distress syndrome). Because the cause and effect between the ARDS and the COVID-19 is documented, it is appropriate to code the ARDS first followed by the code for COVID-19.

Example #3: A 25-year-old male who recently traveled to China with his family presents with a 2 day history of dry cough and a fever of 100.5 degrees Fahrenheit. His father was recently diagnosed with COVID-19 and was also traveling with him. The emergency room physician provides a level 4 ER visit including ordering a chest x-ray to rule out more severe respiratory disease and ordering a test for COVID-19 given the patient’s travel history and proximity to a family member who is positive for the virus. Test results will take another 1-2 days to return. What is the appropriate coding for the ER physician’s work?

Answer Example #3: CPT code is 99284 (for a level 4 emergency room visit). The ICD-10-CM codes for the ER physician will be R05 (cough), R50.9 (fever, unspecified), and Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases).While the patient could certainly have COVID-19 given his recent travel to China and the fact that a close family member already has the disease, his test results are still pending at this time. Remember to only code B97.29 or U07.1 if the diagnosis of COVID-19 is definitive. For now, we should code the signs/symptoms he presented with (the cough and the fever) and his known contact with/exposure to COVID-19 through contact with his dad. **Updated 8/2/2020: The most recent AHA guidance suggests holding the claim for the test results to come back to ensure accurate coding of COVID-related diagnoses. Work with your employer/healthcare institution on the best coding protocols for your patients and specialty.**

To read the CDC’s guidance in its entirety, you can click on the following link: https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf.