Category: Article

Many times when I’m working with coders and refer to a guideline that lead me to my conclusion on how to code a specific procedure, the coder will ask me how they can find the guidelines I’m referencing for themselves. One of the first keys to being a successful coder is building your library of coding resources that will help you along the way. This article is dedicated to sharing with you all some of the resources that help me with my daily work.

• The CPT guidelines: While this may seem like an obvious one, it’s amazing how many times I see a coder make an error on a case because they weren’t aware of the CPT guidelines for that code. The CPT guidelines include the paragraphs of information that appear before a particular range of CPT codes or the parenthetical guidelines that might appear underneath different codes throughout the manual to guide us on appropriate use of the codes. The paragraphs of information throughout CPT often provide key definitions to help us better understand the intent of the codes while the parenthetical guidelines usually provide key rules for how the codes should be used (e.g., notes telling us to code also a second CPT to represent two procedures commonly performed together or to refrain from coding two CPT codes together based on the rules of use for that code).

 

• The Coder’s Desk Reference: The Coder’s Desk Reference is an Optum product that provides lay descriptions for all CPT            codes. These lay descriptions provide an explanation of that particular code and the procedures that would be included in that code from the start of the procedure to the end of the procedure in easy to understand language. For example, CPT 49560 which is for open repair of an initial ventral or incisional hernia describes how the physician makes an open incision overlying the hernia, reduces or removes the hernia sac, closes the facial defect (the hernia defect itself), and then closes the abdominal wall in layers. The goal of this resource is to help surgery coders specifically know if they are picking a code that accurately reflects the procedure their surgeon performed (the coder is able to “line up” some of the language from the operative report with the language in the lay description to see if the two are a match). This tool can also be helpful to understanding what parts of a procedure are integral  (meaning they are a routine part of the procedure and should not be coded with an additional CPT code(s)). The Coder’s Desk Reference is available for purchase as a stand-alone product through the publisher Optum: Coder’s Desk Reference. It is also available through other third-party websites and is often offered as part of coding software packages such as Optum Encoder Pro or Supercoder.

 

• CPT Assist:  CPT Assistant (known as CPT Assist for short) is a publication from the American Medical Association (AMA). The AMA is the governing body that publishes the CPT manual each year. CPT Assist is a publication where the AMA answers frequently asked questions from coders and physicians or where they explain guidelines for CPT codes/topics that aren’t abundantly clear in the CPT manual. Often, the AMA will answer a coding question and also provide a clinical vignette to illustrate the correct use of the CPT code. This publication is available for direct purchase from the AMA: CPT Assist. It is also available as an add on module for purchase as part of coding software packages such as Optum Encoder Pro.

 

• NCCI Edits: The National Correct Coding Initiative (NCCI) edits are published by Medicare each quarter (in January, April, July, and October). The purpose of the NCCI edits is to prevent inappropriate reporting of procedures that are considered a routine part of the main procedure being performed. When coders and physicians report multiple CPT codes when one or more of those codes is considered a routine part of the main procedure, the practice is know as unbundling. While the NCCI edits are a Medicare product and Medicare Administrative Contractors processing claims will always follow the NCCI edits, many commercial carriers also follow the NCCI edits (you may find some small payers that do not follow NCCI and develop their own editing policies, but those payers are growing more rare as NCCI has become a nationally-accepted standard for correct coding and referenced by many non-Medicare payers). You can usually check your payer contracts to see if they are following NCCI or find this information through a simple Google search (e.g., “does United Healthcare follow NCCI edits?”) The NCCI edit tables can be downloaded from the Medicare website each quarter:  NCCI Edit Tables. These edits can also be checked in coding software such as Encoder Pro and Supercoder which offer built-in CCI edit check tools.

 

• NCCI Policy Manual: The NCCI Policy Manual is a tool designed to be used in conjunction with the NCCI edit tables. This policy manual is published by Medicare and updated each January. The NCCI Policy Manual explains the reason for many of the edits that exist in the NCCI edit tables. The policy manual also explains certain correct coding rules for which no edits exist. The introduction chapter to the NCCI policy manual states that the NCCI edit tables are designed to represent the most common forms of unbundling that exist, but even in the absence of an NCCI edit, providers and coders are expected to code correctly. To explain that statement further, it is not good enough to simply check your NCCI edits and report two codes together simply because no edit exists. You must consider all coding guidelines and policies including the CPT guidelines and the rules outlined in the NCCI Policy Manual in your coding. The NCCI Policy Manual is available for download from the CMS website: NCCI Policy Manual. The current manual is titled “NCCI Policy Manual for Medicare Services – effective January 1, 2018” and can be found in the “downloads” box once you arrive at the website.

 

• CMS Modifier 59 Article: As important as it is to know whether an NCCI edit exists between two codes, it’s equally important to know why that edit exists and when it would be appropriate to bypass the edit with a modifier 59 or one of the new EPSU modifiers from Medicare (I will talk more about these EPSU modifiers in a future article). The CMS Modifier 59 Article is a key resource to understanding NCCI edits and when you would and would not bypass those edits. The article stresses the fact that just because the edit between two codes allows for a modifier to bypass the edit does not mean you should automatically do so.
  The article also provides some helpful examples of when you could unbundle two codes in an NCCI edit pair. This article is available for download from the CMS website: Modifier 59 Article. When you arrive at the website, scroll down to the downloads box and click on “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Services – Updated 11/15/17.”

 

• CMS Examples of NCCI Edits: Another great resource I found from CMS is a 49 page document explaining different reasons NCCI edits may exist and giving clinical examples of those types of edits and appropriate coding. Each NCCI edit is assigned a “reason” for potential bundling in the NCCI edit tables (e.g., standards of medical/surgical practice, more extensive procedure, misuse of a column 1 with a column 2 code, etc.). Each of these reasons has a specific definition in CMS policy and helps us to better understand why the edit exists which in turn can help us know when to bypass the edit and when the edit actually applies to our report and scenario and should not be bypassed. This tool is available for download from the CMS website at the following link: NCCI Edit Examples

 

• CMS Claims Processing Manual Chapter 12: The CMS Claims Processing Manual contains many of the guidelines that Medicare Administrative Contractors (MACs) apply when they are processing claims. Chapter 12 is particularly helpful for surgery coders because it contains the rules for co-surgery, assistants at surgery, billing for mid-level providers (NPs/PAs), teaching facility rules where physicians involve residents in their surgeries, and many other surgery-specific topics. This resource is available for download from the CMS website: Claims Processing Manual.

 

• Medically Unlikely Edits: The Medically Unlikely Edits (MUEs) are also published by Medicare each quarter (in January, April, July, and October). These edits let providers and coders know how often a code is typically expected to be billed by the same physician providing care to the same patient on the same date of service. In addition to looking at the MUE itself which tells you how many times a code would generally be reported on the same date by the same provider, you should also check the MAI indicator (which is the reason the MUE edit exists). This indicator is also referred to as the MUE rationale and lets you know when you may exceed the MUE for a particular code and when the edit is binding. The three MAI indicators for MUE edits are as follows:

1 – Line item edit: This type of edit represents the maximum number of units of a code that may be reported on a single line on a claim. To bypass this edit if you need to report units in excess of the MUE, report the code on more than one line of the claim and link the maximum number of units allowed by the MUE to each line of the claim. For example, if you are reporting a code with an MUE of 3 and an MAI indicator of “line item edit,” and you need to report 6 units of the code based on documentation report the code once on the first line of the claim with units of 3 and then report a second line of code with the same CPT and the remaining 3 units.

  2 – Date of service edit: This type of edit represents the maximum number of units of a code that may be reported by the same  physician for the same patient on the same date of service. These edits are considered “binding” on providers and contractors     processing claims based on anatomy or the definition of a code. In other words, you absolutely cannot code in excess of the MUE for a code with this MAI indicator (to do so is considered a coding error per Medicare guidelines).

 3 – Date of service edit: This type of edit represents the maximum number of units of a code that Medicare expects to be reported by the same physician for the same patient on the same date of service. This edit is similar to the MAI indicator of 2, but unlike that edit, this type of MUE edit may be exceeded when documentation supports coding in excess of the MUEs for a particular CPT code(s). Be prepared to submit documentation supporting the fact that exceeding the MUE for the code is appropriate since Medicare views reporting more units than that typically allowed to be the exception not the norm.

The MUE edit tables which contain the MUEs and the MAI indicators is available for download from the CMS website: MUE Edit Tables. When you arrive at the website, scroll down to the “downloads” box and click on the Practitioner MUE tables link for the current quarter.

I hope you find these resources helpful! How about you – what coding resources do you find helpful when coding surgical and diagnostic procedures? Share your favorite resources in the comments. Coding is a team sport, and you never how a great resource you have discovered might help a fellow coder.

 

Last year we saw some notable changes to coding for diagnostic and therapeutic procedures performed in arteriovenous fistulas and grafts. Nine new procedure codes for percutaneous procedures performed in arteriovenous fistulas and grafts were created in 2017.

Before we look at the individual CPT codes and what procedure each one represents, it’s important to understand some key terms/definitions in the CPT manual that will help us understand the codes and apply them correctly:

• Arteriovenous fistula: An intentional connection between an artery and a vein that is surgically-created to allow a patient to receive dialysis. The point at which the artery and the vein connect is known as an anastomosis. 
• Arteriovenous graft: Placement of a piece of vein from the patient’s own body or synthetic material (e.g., PTFE) to intentionally connect an artery and a vein to allow a patient to receive dialysis. With an arteriovenous graft, there are two anastomoses – one to the artery on one end of the graft and the other to the vein on the other end of the graft.
• Arterial anastomosis: In an arteriovenous fistula, this is the single anastomosis between the artery and the vein. In an arteriovenous graft, this is the anastomosis between the artery and the one end of the graft attached to the artery. 
• Dialysis circuit: A term used in CPT interchangeably to refer to an arteriovenous fistula or an arteriovenous graft. The dialysis circuit begins with the arterial anastomosis and ends where the superior or inferior vena cava are connected to the right atrium of the heart.
• Peripheral segment: The part of the dialysis circuit that begins with the arterial anastomosis and continues through the entire axillary vein or cephalic vein for a dialysis circuit in the arm (whether the termination point of the peripheral segment is the end of the axillary vein or the cephalic vein will depend on the vein involved in the arteriovenous fistula or graft). For example, if the basilic vein is connected to an artery to form an arteriovenous fistula, the venous outflow will be the axillary artery. If you are a visual learner like me, check out this picture of the veins of the arm to help you visualize and understand all the anatomy of these vessels and how far the peripheral segment would extend: Picture of Arm Veins. In rare cases where the dialysis circuit is placed in the leg, the peripheral segment begins at the arterial anastomosis and continues through the entire common femoral vein: Picture of Leg Veins
• Central segment: The part of the dialysis circuit that begins with the central veins (the subclavian and the innominate veins) and continues through the superior vena cava to the right atrium of the heart for a dialysis circuit in the arm. In rare cases where the dialysis circuit is placed in the leg, the central segment begins with the iliac veins then continues through the inferior vena cava to the right atrium of the heart. Again if you are a visual learner, check out this link which shows the connection between the inferior and superior vena cavas and the right atrium of the heart to help you visualize how far the dialysis circuit continues (all the way into the chest until these major veins empty into the heart): Termination Point for Dialysis Circuits.
• “In/through the dialysis circuit”: The coding guidelines and examples you may see from coding consultants will often make reference to using the codes we will discuss today for a procedure performed “in” or “through” the dialysis circuit. A procedure performed “in/through” the dialysis circuit is any procedure (e.g., angioplasty, stent, etc.) performed by placing a needle(s) or catheter(s) into a structure that is part of the dialysis circuit. Again, the dialysis circuit runs from the arterial anastomosis to the juncture where the inferior or superior vena cava joins the right atrium of the heart so if a needle or catheter is inserted in any point along this track, the procedure is stated to be performed “in/through the dialysis circuit.”
• Peri-anastomotic region: The portion of the dialysis circuit that includes a small part of the native artery immediately adjacent to the arterial anastomosis where that artery is joined to a vein or the end of a graft to form a dialysis circuit; the anastomosis itself; and the part of the vein/graft immediately adjacent to the arterial anastomosis. Any interventions performed in this region even if they are in the small segment of the native artery adjacent to the arterial anastomosis are considered “in the dialysis circuit” and may not be reported separately.

 

Now that we have established some of these key terms, let’s take a look at the codes themselves to see what each one includes. These first six codes are progressive hierarchal codes (codes where each code in the series includes the work of the code(s) that preceded it). This concept is important to understanding how these codes are used when multiple procedures occur in the same dialysis circuit.

CPT 36901 is the first code in the series and is used to report a diagnostic fistulogram. This procedure involves introducing a needle or catheter into the fistula/graft, injecting dye, and then obtaining images of the dialysis circuit. Physicians may use the term “angiogram” to describe a fistulogram. An angiogram is an image of a blood vessel(s) taken after introduction of dye to allow the physician to view the blood vessel and when this procedure occurs in/through a dialysis circuit, the term angiogram and diagnostic fistulogram are synonyms. This procedure can be helpful to diagnose complications of the dialysis circuit such as clot, stenosis, or pseudoaneurysm. This code includes introducing one or more needles/catheters into the dialysis circuit, the injection of contrast, the work of obtaining images, and the physician’s interpretation. This code includes obtaining and interpreting images in the peripheral and central segments of the dialysis circuit as necessary (the exact images obtained and commented on by the physician will depend on the patient’s symptoms and the area of the dialysis circuit that is of concern).

CPT 36902 is the second code in the series and is used to report an angioplasty in the peripheral segment. An angioplasty involves inserting a small balloon which is inflated to open up an artery/vein so blood can flow through it freely. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the angioplasty procedure. If more than one angioplasty is needed in the peripheral segment, CPT 36902 is reported only once to capture all angioplasties in the peripheral segment. Also, because these first six codes are progressive hierarchal codes , if a diagnostic fistulogram is needed in addition to the angioplasty, the fistulogram is also included in this code. Coders should not report both 36902 and 36901 together when these procedures are performed in the same dialysis circuit.

CPT 36903 is the third code in the series and is used to report a stent placement in the peripheral segment. A stent is a tube-like device that can be inserted into an artery or vein and expanded to provide support for the walls of the artery or vein and keep them open so blood can flow through the vessel freely. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the stent procedure. If more than one stent is needed in the peripheral segment, CPT 36903 is reported only once to capture all stents in the peripheral segment. Also, because these codes are progressive hierarchal codes, if an angioplasty in the peripheral segment and/or a diagnostic fistulogram are also needed in addition to the stent, the angioplasty and/or fistulogram are also included in this code. Coders should not report CPT 36903 with 36902 and/or 36901 when these procedures are performed in the same dialysis circuit.

CPT 36904 is the fourth code in the series and is used to report percutaneous procedures to remove blood clots (aka thrombus) from the dialysis circuit. Unlike the codes we’ve talked about to point, this procedure code covers clot removal from the entire dialysis circuit (peripheral segment and/or central segment as needed). Methods for removing these blood clots can include mechanical thrombectomy which involves inserting a catheter with a device that breaks up clots and allows them to be removed. They may also include infusions like a TPA infusion to dissolve the clots. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the percutaneous clot removal procedure. Also, because these codes are progressive hierarchal codes, if a diagnostic fistulogram is needed in addition to the percutaneous clot removal procedure, the fistulogram is also included in this code. Coders should not report 36904 and 36901 together when these procedures are performed in the same dialysis circuit. If a percutaneous clot removal procedure occurs in addition to a peripheral segment angioplasty or stent, there are combination codes for that (see CPT 36905 and 36906 below). Do not report 36904 with 36902 and/or 36903 in the same dialysis circuit.

CPT 36905 is the fifth code in the series and is used to report percutaneous procedures to remove blood clots plus an angioplasty procedure in the peripheral segment of the dialysis circuit. This code includes the work of CPT codes 36902 and 36904 combined. Because these codes are progressive hierarchal codes, if a diagnostic fistulogram is needed in addition to the percutaneous clot removal and angioplasty procedures, the fistulogram is also included in this code. Coders should not report 36905 and 36901 together when these procedures are performed in the same dialysis circuit. Again coders also should not report 36904 and 36902 together when percutaneous clot removal and peripheral segment angioplasty are performed in the same dialysis circuit (this one combination code 36905 represents the work of those two codes together).

CPT 36906 is the sixth code in the series and is used to report percutaneous procedures to remove blood clots plus a stent placement in the peripheral segment of the dialysis circuit. This code includes the work of CPT codes 36903 and 36904 combined. Because these codes are progressive hierarchal codes, if a diagnostic fistulogram and/or an angioplasty in the peripheral segment are needed in addition to the percutaneous clot removal and stent procedures, the fistulogram and/or angioplasty are also included in this code. Coders should not report 36902, 36905, or 36901 with CPT 36906 when these procedures are performed in the same dialysis circuit or report those individual codes together. This one code includes all the work described by those codes combined.

Unlike the codes we’ve talked about to point, the next two codes represent procedures performed in the central segment of the dialysis graft:

CPT 36907 is the seventh code in the series and is used to report an angioplasty in the central segment. Just like CPT 36902, this procedure involves inserting a small balloon which is inflated to open up a vein so blood can flow through it freely. The only difference between these two codes is that CPT 36902 represents this work in the peripheral segment while CPT 36907 represents this work in the central segment. Because CPT 36907 represents work in a different segment of the dialysis circuit, this code may be reported in additon to CPT codes 36901-36906. In fact, CPT 36907 is an add on code which means it may never be reported by itself. You must first report a code from CPT range 36818-36833 or a code from CPT range 36901-36906.

CPT 36908 is the eighth code in the series and is used to report a stent placement in the central segment. Just like CPT 36903, this procedure involves inserting a tube-like device into a vein which is expanded to provide support for the walls of the artery or vein and keep them open so blood can flow through the vessel freely. The only difference between these two codes is that CPT 36903 represents this work in the peripheral segment while CPT 36908 represents this work in the central segment. Because CPT 36908 represents work in a different segment of the dialysis circuit, this code may be reported in addition to CPT codes 36901-36906. In fact, CPT 36908 is an add on code which means it may never be reported by itself. You must first report a code from CPT range 36818-36833 or a code from CPT range 36901-36906.

The ninth and final code in the series represents work that may occur in one or both segments of the dialysis circuit or in accessory veins connected to and accessed through the dialysis circuit.

CPT 36909 is reported for vascular embolization or occlusion that occurs in the main dialysis circuit itself or in the accessory veins (small veins connected to the dialysis circuit that can cause lower blood flow in the dialysis circuit). A vascular embolization or occlusion involves placing devices such as coils, beads, or other vessel blocking devices to completely occlude an accessory vein and/or to partially occlude a vein and improve flow in the dialysis circuit. This code includes the work of placing one or more needles and/or catheters into the dialysis circuit and introducing one or more of these vessel occluding devices into the circuit itself or into the accessory veins. This code is reported only once per dialysis circuit regardless of how many vessel occluding devices are placed. CPT 36909 is an add on code and can never be reported by itself. We must first report a code from CPT range 36901-36906 in order to report this code.

Okay time to put these codes and definitions into action with some examples.

Example 1: A 76 year old patient presents with a non-functioning arteriovenous fistula.  A fistulogram with possible intervention is recommended. The right arm was prepped and draped, and a 21 gauge needle was introduced into the cephalic vein just beyond the arterial anastomosis. An angiogram was performed showing a widely patent fistula throughout the peripheral segment. In the innominate vein, a high-grade stenosis was observed. Therefore, a 6 french sheath was threaded from the cephalic vein to the level of the observed stenosis, and angioplasty was performed. A completion angiogram revealed improved flow and no further stenosis in the innominate vein. The sheath was withdrawn and pressure applied to ensure control of bleeding. The patient was transferred to recovery in stable condition.

Answer Example 1: In this example, we see the physician start off by introducing a needle into the dialysis circuit (he’s in the cephalic vein just beyond the arterial anastomosis in the peripheral segment). He then performs a diagnostic fistulogram (he uses the word “angiogram” but remember an angiogram is just a picture of a blood vessel taken after dye is injected so the physician can see the blood vessel and when this procedure occurs in a dialysis circuit, it’s known more specifically as a diagnostic fistulogram). He then provides us with his interpretation of that diagnostic fistulogram. The peripheral segment is patent – all blood vessels are open with normal flow. The innominate vein which is in the central segment has a high-grade stenosis – a significant area of narrowing in the blood vessel. He then introduces a sheath (aka a catheter) and threads that to the level of the observed stenosis (in the innominate vein) and performs an angioplasty. This angioplasty in the innominate vein is in the central segment.  Our code for the angioplasty is CPT 36907  since the angioplasty occurs in the central segment. Because CPT 36907 is an add on code, we will report the work that occurred during the diagnostic fistulogram first with CPT 36901 so we have our primary CPT code and then report the add on code 36907 for the central segment angioplasty.

Example 2: A 54 year old patient presents with a non-maturing fistula. Her nephrologist is concerned she may have large accessory veins causing poor flow in her fistula. The patient is brought in for a fistulogram to better assess the anatomy and determine next steps. After sterile prep and drap, a 21 gauge needle is used to enter the basilic vein in the left arm. Dye is introduced and images obtained. Fistulogram reveals the presence of multiple large collateral veins causing abnormally low flow in the dialysis circuit throughout the peripheral segment. A 5 French sheath is introduced, and one at a time, each of these large collateral veins were selectively engaged and embolization coils placed. A completion fistulogram shows improved flow in the circuit and the decision was made to terminate the procedure. The patient was wheeled to recovery in stable condition.

Answer Example 2: In this example, we see the physician start off by introducing a needle into the dialysis circuit (he’s in the basilic vein in the peripheral segment of the dialysis circuit). He then performs a fistulogram (this time he actually uses the term fistulogram but angiogram would have been an acceptable synonym here as well). He introduces dye and obtains images of the dialysis circuit (here is describing the steps of performing the fistulogram). He then provides an interpretation that there are multiple large collateral veins causing poor flow in the fistula. Note that “collateral veins” is a synonym for “accessory veins.” Once he’s identified these collateral veins as the cause of the problem in the fistula, he threads a catheter into each collateral vein and places “embolization coils” (which are a type of vessel occluding device). He then notes improved flow in the fistula. We will report CPT 36909 for the placement of the embolization coils. Even though he places more than one coil, we report CPT 36909 only once for all vessel occlusion devices placed in the same dialysis circuit/accessory veins of that dialysis circuit. Because CPT 36909 is an add on code and may not be reported by itself, we will also report CPT 36901 for the diagnostic fistulogram at the start of the case which gives us a valid primary code for our add on code 36909.

Example 3: A 61 year old patient presents with complaints of poor flow in her AV graft during recent dialysis. A diagnostic fistulogram was performed in radiology yesterday revealing a high grade stenosis in the graft body as well as in the axillary vein. The patient also has thrombus at the arterial anastomosis. The decision was made to bring her to the OR today for thrombectomy and stent placement.

After sterile prep and drape, a small puncture was made overlying the graft just distal to the arterial anastomosis. A catheter was introduced and mechanical thrombectomy was performed disrupting the known clot at the arterial anastomosis. The catheter was then threaded towards the venous side of the graft in the area of the previously identified stenosis. Balloon angioplasty was performed followed by placement of a Viabahn stent. Finally, the catheter was threaded up the venous outflow the area of previously identified stenosis in the axillary vein. A balloon angioplasty was performed to open up the venous outflow. A completion angiogram was obtained showing no evidence of further clot or stenosis. This concluded the procedure, and the patient was transferred to recovery in stable condition.

Answer Example 3: In this case, the physician starts off by giving us the results of a recent fistulogram performed by the interventional radiologist so he is not personally performing the fistulogram. Based on those results, he’s already decided to perform a thrombus removal and stent placement. He starts off by introducing a catheter into the dialysis circuit in the graft body itself (which means the puncture and subsequent catheter placement was directly into the piece of graft connecting the artery and the vein over in the peripheral segment). He then begins with a mechanical thrombectomy at the arterial anastomosis to break up the clot. After completing the mechanical thrombectomy, he moves further into the graft closer to where it connects to the vein and finds the area of stenosis where he performs a balloon angioplasty followed by placement of a stent. Finally, he moves further up the venous outflow of the dialysis circuit into the axillary vein where he does one final balloon angioplasty of an area of stenosis. Note that he is still in the peripheral segment with this last procedure since he is in the axillary vein. So all of the procedures in this case are in the peripheral segment and they include mechanical thrombectomy plus a stent placement plus two balloon angioplasties. This documentation supports CPT 36906. This one combination code includes a thrombus removal plus a stent placement in the peripheral segment. Also because these codes are progressive hierarchal codes the angioplasties which both occur in the peripheral segment are included and may not be reported separately.

These cases illustrate some common percutaneous procedures you may encounter in AV dialysis circuits. Be sure to check back for our next article as well where we will discuss some challenges of coding AV dialysis circuit procedures when some procedures are performed through a percutaneous approach (the procedure codes we have discussed here) and some are performed through an open incision overlying the dialysis circuit. We will also talk about how to code cases where percutaneous procedures occur in the dialysis circuit but the approach to the procedure is through puncture of a blood vessel outside of the dialysis circuit which changes your CPT codes.

Today’s article is a continuation of our previous article about hernia repair coding. The goal of this article is to provide some examples of hernia repair notes and apply the method taught in the first article to determine how to code these examples. If you haven’t checked out the previous article, I encourage you to do so to gain the most benefit from the coding examples featured here: https://codingmastery.com/2018/07/28/hernia-repair-coding/.

Example #1:

Preoperative diagnosis: Incarcerated hernia
Postoperative diagnosis: Incarcerated hernia

Indications for procedure: Patient is a 44 year old female with a prior history of colectomy due to diverticulitis. Along the inferior
aspect of her previous midline incision, she noted a bulge that started 2 months ago. This morning she had a sudden onset of severe
abdominal pain and presented to the ER. Exam and CT scan revealed an incarcerated incisional hernia, and the patient was taken urgently to the OR.

Description of procedure:Patient was sterilely prepped and draped. A surgical time out was performed to confirm the appropriate patient and site for surgical incision. Using a 10-blade, an incision was made beginning at the superior aspect of the prior incision and carried down to the inferior aspect completely exposing the hernia defect. The hernia sac was entered, and incarcerated bowel and omentum were immediately observed. After lysing adhesions, the omentum and bowel were freed from the hernia sac and allowed to retract back into the abdomen. Bowel was inspected to ensure viability, and no areas of ischemia were noted. Therefore, we elected not to resect the bowel at this time.

We then resected the redundant tissues of the hernia sac and assessed our hernia defect. It was too large to repair primarily so we elected to place a piece of Vicryl mesh to ensure adequate repair. We tacked the mesh into place, and we confirmed complete closure of our defect and no injury to the underlying bowel. The tissues of the abdominal wall were then closed in layers beginning with the fascia followed by layered closure in the subcutaneous tissues, and the skin.

A hernia wrap was placed to ensure integrity of the abdominal wall and the patient was transferred to recovery in stable condition.

Let’s use the questions discussed in the previous article to break down the appropriate coding for this case. The items in italics from the note will be important for code selection.

Questions for Example #1:

1. What type of hernia is being repaired? We know from the pre and post operative diagnosis that the hernia is incarcerated but don’t know what type of hernia is present. When we read the indications for procedure we see the bulge which turns out to be a hernia on a CT scan is “at the inferior aspect of the prior incision” and the surgeon diagnoses an incarcerated incisional hernia.
2. Is the hernia reducible or incarcerated? Again if we look at the pre and postoperative diagnosis as well as the indications for  procedure, we see this is an “incarcerated” hernia. Additional details in the body of the operative report that confirm this hernia  is incarcerated include noting that “incarcerated bowel and ometum were observed” and then “freed from the hernia sac” (so these  incarcerated organs had to be surgically freed from the hernia).
3. What is the approach to the hernia repair? In the second sentence of the first paragraph of the description of the procedure, we see that the surgeon used a scalpel and made an incision along the prior incision from the colectomy mentioned in the                  indications for procedure and “carries that down….completely exposing the hernia defect.” So the surgeon is using an “incision”      and “directly visualizing the hernia defect” which makes this an open approach. 
4. Is this the initial hernia repair or a subsequent hernia repair in this same site? While the patient has had a prior surgery (a colectomy), there is no mention of a hernia in this same site along the incision line of the prior colectomy. Therefore, this is an initial hernia repair. 
5. Did the physician use mesh to repair the hernia? In the second paragraph of the report, we see the physician mention that the hernia defect is too large to repair primarily (which is another way of saying he cannot simply place sutures and repair the defect with sutures alone). So he “decides to place a piece of Vicryl mesh.” Therefore, this repair was performed with mesh.
6. How old is the patient? In this example, the patient is 44 years old (per the indications for procedure). The patient’s age will not affect our code based on the the type of hernia repair in this case, but there are some hernia repairs, especially open inguinal hernia repairs, that may be impacted by patient age. While this example includes the patient’s age in the note itself, the surgeon is not required to dictate the age of the patient specifically (you may pull that information from the patient’s date of birth in their demographics if the patient’s age is important to code selection).

Final coding for example #1: If we put the answers to our questions together we have an incisional hernia that is incarcerated. It is repaired through an open approach, this is the initial repair, and the physician uses mesh. The patient is 44 years old. Based on these details, our documentation supports the following codes:

CPT 49561: Repair initial incisional or ventral hernia; incarcerated. If we read the long description for this code in a software tool like Encoder Pro or a Coder’s Desk Reference we see that the physician “makes an incision” and “directly exposes the hernia defect” making this code appropriate for an open approach. The code description itself in CPT tells us this code is appropriate for an initial repair of an incisional hernia that is incarcerated.

CPT 49568: Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair). CPT 49568 is an “add on code.” It may never be reported by itself and must be reported in addition to a primary CPT code defined by the CPT guidelines. In the description we see this code is for implantation of mesh “for open incisional or ventral hernia repairs” (which fits our case) and that the guideline in parentheses tells us to “list separately in addition to code for the incisional or ventral hernia repair.” So we will report both CPT 49561 and 49568 in this example.

 

Example #2:

Preoperative diagnosis: LIH
Postoperative diagnosis: LIH

Procedure title: Laparoscopic repair of a left inguinal hernia

Indications for procedure: Patient is a 26 year old male who is an avid athlete and began experiencing pain in his
left groin 6 weeks ago. He presented as a consult from his primary care physician and was diagnosed with a left
inguinal hernia. Due to his young age, lack of any previous surgical history, and desire to return to his normal
activity level as quickly as possible, we discussed a laparoscopic repair. Risks and benefits were discussed with the patient,
and all of his questions answered. He presents today for elective repair.

Description of Procedure: After sterile prep and drape and a mandatory surgical time out, a small incision was made in the LLQ
and a port was placed. Additional ports were placed in the umbilical position and the RUQ. The abdomen was insufflated and the
scope was introduced. A survey of the abdomen was performed revealing no other pathology. The right groin was approached first
and no defect was noted. Then we approached the left groin where the hernia defect was immediately apparent. The hernia sac was excised confirming appropriate reduction. We then placed a small onlay mesh to ensure integrity of the repair given his young age and activity status. We tacked the mesh patch in place and confirmed successful repair of this defect. The abdomen was desufflated, ports were removed, and incisions were closed.

The patient was transferred to the recovery room in stable condition. He will follow up with me postoperatively in two weeks.
He was instructed to call right away if he had excessive drainage from the incision site, fever over 100 degrees Fahrenheit,
redness, excessive swelling, acute onset of pain, or any other signs of infection.

Questions for Example #2:

1. What type of hernia is being repaired? We know from the pre and post operative diagnosis that the hernia is an LIH (which an acronym meaning “left inguinal hernia”). In our particular example here, the surgeon goes on to tell us in the title of the report and the indications for procedure that this is a “left inguinal hernia” making the meaning of the acronym very clear, but this will not always be the case in operative reports you encounter on a daily basis. If you are unfamiliar with an acronym that appears in a report, use Google to do some research. A great acronymn website for medical abbreviations is Acronym Finder: https://acronymfinder.com/. This site allows you to type in an acronym and view potential meanings based on different contexts in which it may be used such as Science & Medicine or Military & Government.
2. Is the hernia reducible or incarcerated? If we look at our pre and postoperative diagnosis in this case, we know the type of hernia (inguinal) but not whether it is incarcerated or reducible. In the body of the report, the surgeon excises the hernia sac but does not note the presence of any incarcerated organs so this is a reducible hernia. Another clue that the hernia is likely not incarcerated is the fact the patient comes in for an elective repair per the indications for procedure (as opposed to an urgent/emergent repair we saw for the patient with an incarcerated hernia in example #1).
3. What is the approach to the hernia repair? In the title of the procedure, we see the word “laparoscopic.” Even if this word were missing, though, we have several clues in the body of the report that would allow us to determine the approach. In the first paragraph of the report, we see notations of “multiple small incisions,” “placing ports”, “insufflating the abdomen,” and introducing a scope, all of which point to a laparoscopic repair. In the last paragraph of the report,we see reversal of all these steps when the surgeon “desufflates the abdomen,” “removes the ports,” and “closes the incisions” (confirming this was a laparoscopic approach throughout the entire procedure).
4. Is this the initial hernia repair or a subsequent hernia repair in this same site? We see no mention of a prior hernia repair at this site, and the patient recently started having pain (about 6 weeks ago) so this is an initial repair.
5. Did the physician use mesh to repair the hernia? In the last paragraph of the report, we see the surgeon mention using an “onlay mesh” to ensure the repair is sufficient. Therefore, this repair was performed with mesh. Not all hernia repairs performed with mesh will allow us to separately report placement of the mesh, but we will break down this part of the repair in our final coding.
6. How old is the patient? In this example, the patient is 26 years old (per the indications for procedure). Again, the patient’s age will not always affect the code, and the surgeon is not required to dictate the age of the patient specifically (you may pull that information from the patient’s date of birth in their demographics if the patient’s age is important to code selection).

Final coding for example #2: If we put the answers to our questions together we have an inguinal hernia that is reducible. It is repaired through a laparoscopic approach, this is the initial repair, and the physician uses mesh. The patient is 26 years old. Based on these details, our documentation supports the following code:

CPT 49650: Laparoscopy surgical; repair, initial inguinal hernia. We see from the CPT description that this code is appropriate for a laparoscopic approach for an inguinal hernia and for an initial repair. Notice that the concept of reducible or incarcerated and the patient’s age is not addressed in the laparoscopic CPT codes for inguinal hernias. If the procedure was significantly complicated by the patient’s young age requiring the surgeon to work in a smaller space or by incarcerated organs that needed to be reduced, you could consider adding a modifier 22 since there are no dedicated codes to represent these variables when it comes to laparoscopic hernia repairs.

Mesh placement: While the surgeon placed mesh to repair the hernia, the CPT guidelines state that with the exception of open incisional or ventral hernia repairs (49560-49566), the insertion of mesh or other prosthesis is not separately reportable. Therefore, we cannot report CPT 49568 for insertion of mesh like we could in the first example. The mesh placement is considered included in CPT 49650.

Using this method to break down your hernia repair notes will help you pick accurate codes with each case.

Hernia repairs are a procedure that all general surgery coders will encounter many times in their career. Understanding what a hernia is and the different types of repairs that may be performed will help you ask the right questions to find the keys in your operative report and code this commonly-performed procedure correctly.

A hernia is simply a weakness in the muscle of the abdominal wall, the groin, the thigh, or the diaphragm that allow organs to become displaced.  The organ that most often protrudes through this muscle weakness is the intestine, but the omentum,the ovaries, the testicles, and even parts of major abdominal organs like the stomach can protrude through a hernia defect depending on where the hernia is located and how large the area of weakness (also known as a hernia defect) is. When coding hernia repairs, I typically ask myself six key questions to ensure I select the correct CPT code.

Question #1:  “What type of hernia is being repaired?” The “type” of hernia refers to the name of the hernia based on where it is located.  Below are some hernias you may see: Continue reading “Hernia Repair Coding” →