EOS FLASH CARDS 2-RANDOM TIDBITS
Orthopedic procedures are coded by the surgical approach to the procedure.
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Wound exploration codes are for traumatic wounds that result from acute or penetrating trauma (such as gunshot or stabbing).
Wound exploration codes are also used when the repair requires enlargement of the existing wound for cleaning, determination of the extent of the wound, and repair.
The following rules apply when coding Wound Explorations:
Wound explorations are reported in addition to the E/M service appended with modifier -25. Codes are used for acute and penetrating injuries only. Surgical exploration is through the current wound with possible enlargement. Muscle fascia and beyond are explored. Skin and subcutaneous tissue exploration is coded to the Repair codes in the Integumentary section when no enlargement of the wound, extension, dissection, or the like is required. Layered closure is expected and not reported separately. Drains may or may not be placed. Debridement and removal of foreign body is included and not reported separately. Ligation of minor subcutaneous tissue and/or muscle blood vessels is included and not reported separately. If Wound Exploration results is a thoracotomy or laparotomy or other more extensive procedure being performed, the wound exploration is bundled into these more extensive procedures.
Trigger point injections, usually done for pain management, are coded by the number of muscle groups injected, not the number of times the needle is inserted.
Two factors affect coding for removal of a foreign body:
- The site; and
- Whether the foreign body is superficial or deep.
All fractures and dislocations are reported based on the reason for the treatment.
Application or removal of the first cast or traction device is bundled for all orthopedic procedures, so if a cast, splint, or strapping is applied as a result of of or during a surgical procedure, it is not assigned a code
The main challenge in bronchoscopy coding comes when multiple procedures are performed. Although they may occur during the same session, biopsies on different lesions and/or anatomic sites are separate and can be coded as such.
Sometimes a bronchoscopy includes multiple procedures performed on the same or different parts of the lung. When procedures such as bronchial brushings or alveolar lavage are performed on the same or different lobes with other procedures, use modifier -51.
To correctly code CABGs:
- Identify whether an artery, vein, or both are being used as the bypass graft
- Identify how many bypass grafts are being done.
Ipsilateral: Situated, or appearing on the same side, or affecting the same side of the body;
Contralateral: Pertaining to, located on, or occurring in or on the opposite side;
Antegrade: Extending or moving forward; and
Retrograde: Moving backward, against the normal flow.
Every Interventional Radiology procedure begins with accessing the vascular system
Vascular order (arterial or venous) describes the furthest point to which the catheter is placed into the branches of vessel originating off the aorta, vena cava, or vessel punctured and is referred to as the “level of selectivity.”
The coder must always follow five component coding rules when coding Interventional Radiology procedures:
Each vascular family must be coded separately. Each time the physician reenters the aorta to move the catheter to another branch originating off the aorta, a new vascular family is entered and should be coded independently from any other procedures that are being performed during the encounter. Modifier -59 modifier (Distinct Procedural Service) may be appended to identify the catheterizations of vessels in different families as distinct services. The coder must code to the highest order of selectivity within a vascular family. The lower-order selective vessels that were manipulated through to get to the higher-order selective vessel are included in the code for the higher-order selective catheter placement. Count the number of bifurcations passed to help determine the second or third order. EXAMPLE: The patient's right common femoral artery is accessed. The catheter is moved retrograde to the aortic bifurcation and then maneuvered contralaterally through the left common iliac artery to the left common femoral artery where injection and angiography are performed. The correct catheter placement surgical code assignment would be 36246 as the left common femoral artery is a second-order selective vessel.; radiology code 75710 would be assigned for the left lower extremity angiography. Code 36245 is not assigned as the left common iliac artery is transversed to get to the final destination of the left common femoral artery and is included in the code for this higher-order selective vessel. The code for selective catheter placement takes precedence over the code for nonselective catheter placement if done from the same puncture site. The coder would only use a code fro selective catheter placement when both nonselective and selective catheter placement are performed from the same puncture site to reach the target vessel. EXAMPLE: The patient's left common femoral artery is accessed. The catheter is moved retrograde to the abdominal aorta. An abdominal aortogram is performed. The catheter is then manipulated to the superficial femoral artery where injection and lower extremity angiography is performed. Code 75625 would be assigned for the abdominal aortography and code 75710 would be coded for the lower extremity angiogram. Only one catheter placement code (36247) would be correct because the nonselective catheter placement code 36200, for placement into the abdominal aorta, is included in the selective catheter placement code 36247. The coder must code each vascular access separately. If the physician performs more than one vascular access to the patient's body, each site is coded independently from the others. The main term "Insertion" is a good place to begin in the Alphabetic Index. If more than one second- or third-order selective branch in the same vascular family is entered during the procedure, the additional selective catheterization must be coded as: 36218 (Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family) for vessels above the diaphragm; or 36248 (Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family) for vessels below the diaphragm. Both of these codes are add-on codes. 36218 and 36248 may be assigned multiple times, as needed.
In addition to diagnostic catheter placements, therapeutic procedures can be performed, which require additional surgical codes. Angioplasty uses a balloon to dilate a narrowed vessel. Angioplasty codes are assigned per vessel treated, not per stenosis.
Surgical codes are specific to the artery treated, while the radiologic S&I codes for angioplasty are general, with three categories:
Peripheral artery; Aorta, renal, or visceral artery; or Venous.
Stent placement can be performed in conjunction with angioplasty. Codes are assigned per vessel treated, not per lesion. Angioplasty may be coded coded separately from stent placement if:
There is suboptimal result; Treatment is of an area not treated by the stent; or Treatment is for dissection or stent-induced stenosis.
Whether a provider actually receives the allowed charge depends on three things:
The provider's usual charge for the procedure or service: The usual charge may be higher, equal to, or lower than the allowed charge. The provider's status in the particular healthcare plan or program: The provider is either participating or nonparticipating. A participating provider (PAR) agrees to accept allowed charges (which are usually 25 to 50% lower than the provider's usual fees - in return for incentives to be part of the plan. For example, providers who are Medicare participants are paid faster than nonparticipating providers (nonPAR). The payer rules: These rules govern whether the provider is permitted to bill a patient for the part of the charge that the payer does not cover.
Whether a participating provider can bill the patient for the difference between a higher usual fee and a lower allowed charge - called balance billing - depends on the payers rules. In most cases, participating may not balance bill the patient for the difference. Instead, the provider must write off the difference, meaning that the amount of the difference is subtracted from the patient’s bill and never collected.
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