Coding & BillingCoding & Billingfor thefor the

Digestive SystemDigestive System

Coding & BillingCoding & Billingfor thefor the

Digestive SystemDigestive System

Denise Hamilton, RHIA, CCS-PDenise Hamilton, RHIA, CCS-P

Joletta Maxile, MBA, RHIA, CCPJoletta Maxile, MBA, RHIA, CCP

Vickie Nitschke. M. Ed, CRSVickie Nitschke. M. Ed, CRS

Denise Hamilton, RHIA, CCS-PDenise Hamilton, RHIA, CCS-P

Joletta Maxile, MBA, RHIA, CCPJoletta Maxile, MBA, RHIA, CCP

Vickie Nitschke. M. Ed, CRSVickie Nitschke. M. Ed, CRS

What is the digestive system?What is the digestive system?What is the digestive system?What is the digestive system?

• Starts with lips, mouth, esophagus, Starts with lips, mouth, esophagus, small and large intestine through small and large intestine through the anusthe anus

• Organs related to food digestion Organs related to food digestion (for example, the liver and (for example, the liver and pancreas)pancreas)

• Starts with lips, mouth, esophagus, Starts with lips, mouth, esophagus, small and large intestine through small and large intestine through the anusthe anus

• Organs related to food digestion Organs related to food digestion (for example, the liver and (for example, the liver and pancreas)pancreas)

DigestiveDigestiveSystemSystem

DigestiveDigestiveSystemSystem

ICD-9 CodesICD-9 CodesICD-9 CodesICD-9 Codes

• Oral Cavity, Salivary Glands, and Jaws

(520 – 529)

• Esophagus, Stomach, and Duodenum

(530 – 537)

• Appendicitis (540 – 543)

• Hernia of Abdominal Cavity

(550 – 553)

• Oral Cavity, Salivary Glands, and Jaws

(520 – 529)

• Esophagus, Stomach, and Duodenum

(530 – 537)

• Appendicitis (540 – 543)

• Hernia of Abdominal Cavity

(550 – 553)

ICD-9 Codes Continued . . .ICD-9 Codes Continued . . .ICD-9 Codes Continued . . .ICD-9 Codes Continued . . .

• Noninfectious Enteritis and ColitisNoninfectious Enteritis and Colitis

(555 – 558)(555 – 558)• Other Diseases of Intestines & PeritoneumOther Diseases of Intestines & Peritoneum

(560 – 569)(560 – 569)

• Other Diseases of Digestive SystemOther Diseases of Digestive System

(570 – 579)(570 – 579)

• Noninfectious Enteritis and ColitisNoninfectious Enteritis and Colitis

(555 – 558)(555 – 558)• Other Diseases of Intestines & PeritoneumOther Diseases of Intestines & Peritoneum

(560 – 569)(560 – 569)

• Other Diseases of Digestive SystemOther Diseases of Digestive System

(570 – 579)(570 – 579)

Abdominal QuadrantsAbdominal QuadrantsAbdominal QuadrantsAbdominal Quadrants

ICD DefinitionsICD DefinitionsICD DefinitionsICD Definitions

• GI hemorrhageGI hemorrhage– HematemesisHematemesis

– MelenaMelena

– Occult bleedingOccult bleeding

– HematocheziaHematochezia

• GI hemorrhageGI hemorrhage– HematemesisHematemesis

– MelenaMelena

– Occult bleedingOccult bleeding

– HematocheziaHematochezia

GI HemorrhageGI HemorrhageGI HemorrhageGI Hemorrhage

• Common causesCommon causes

– Gastric and intestinal ulcersGastric and intestinal ulcers

– Diverticular diseaseDiverticular disease

– HemorrhoidsHemorrhoids

(internal/external)(internal/external)

• Common causesCommon causes

– Gastric and intestinal ulcersGastric and intestinal ulcers

– Diverticular diseaseDiverticular disease

– HemorrhoidsHemorrhoids

(internal/external)(internal/external)

ICD Code 578ICD Code 578ICD Code 578ICD Code 578

• GI hemorrhage - Abnormal escape of GI hemorrhage - Abnormal escape of blood from the GI tractblood from the GI tract

• NOT used when a combo code exists NOT used when a combo code exists for previously mentioned GI for previously mentioned GI conditionsconditions

• Use ONLY when clinician specifically Use ONLY when clinician specifically states bleed not due to GI conditionstates bleed not due to GI condition

• GI hemorrhage - Abnormal escape of GI hemorrhage - Abnormal escape of blood from the GI tractblood from the GI tract

• NOT used when a combo code exists NOT used when a combo code exists for previously mentioned GI for previously mentioned GI conditionsconditions

• Use ONLY when clinician specifically Use ONLY when clinician specifically states bleed not due to GI conditionstates bleed not due to GI condition

Diseases of EsophagusDiseases of EsophagusDiseases of EsophagusDiseases of Esophagus

• ICD Category 530 – Diseases of ICD Category 530 – Diseases of EsophagusEsophagus

• EsophagitisEsophagitis• UlcersUlcers• Stricture/StenosisStricture/Stenosis• PerforationPerforation• DiverticulaDiverticula• OtherOther

• ICD Category 530 – Diseases of ICD Category 530 – Diseases of EsophagusEsophagus

• EsophagitisEsophagitis• UlcersUlcers• Stricture/StenosisStricture/Stenosis• PerforationPerforation• DiverticulaDiverticula• OtherOther

Diagnosis for ScreeningsDiagnosis for ScreeningsDiagnosis for ScreeningsDiagnosis for Screenings

““A screening is a screeningA screening is a screening

is a screening”is a screening”

• Additional condition foundAdditional condition found

• History of condition and foundHistory of condition and found

““A screening is a screeningA screening is a screening

is a screening”is a screening”

• Additional condition foundAdditional condition found

• History of condition and foundHistory of condition and found

Screenings, Etc.Screenings, Etc.Screenings, Etc.Screenings, Etc.

• DX for screeningsDX for screenings– Use V76.51Use V76.51

– Add DX codes as secondary Add DX codes as secondary

• DX for screeningsDX for screenings– Use V76.51Use V76.51

– Add DX codes as secondary Add DX codes as secondary

2005 Changes2005 Changes2005 Changes2005 Changes

Many new Dental codes (520-528)Many new Dental codes (520-528)

New codes in category 530New codes in category 530– 530.86 Infection of 530.86 Infection of

EsophagostomyEsophagostomy

– 530.87 Mechanical Complication 530.87 Mechanical Complication of Esophagostomyof Esophagostomy

Many new Dental codes (520-528)Many new Dental codes (520-528)

New codes in category 530New codes in category 530– 530.86 Infection of 530.86 Infection of

EsophagostomyEsophagostomy

– 530.87 Mechanical Complication 530.87 Mechanical Complication of Esophagostomyof Esophagostomy

CPT CodingCPT CodingCPT CodingCPT Coding

Endoscopic Biopsies Coding GuidelinesEndoscopic Biopsies Coding GuidelinesEndoscopic Biopsies Coding GuidelinesEndoscopic Biopsies Coding Guidelines

• Biopsy performed, but not fully excised, Biopsy performed, but not fully excised, code biopsy only.code biopsy only.

• Biopsy performed and remaining portion Biopsy performed and remaining portion removed, code excision only.removed, code excision only.

• Biopsies performed at the same/different Biopsies performed at the same/different sites of the same organ and without sites of the same organ and without removal, code only the biopsy once.removal, code only the biopsy once.

• Biopsy performed, but not fully excised, Biopsy performed, but not fully excised, code biopsy only.code biopsy only.

• Biopsy performed and remaining portion Biopsy performed and remaining portion removed, code excision only.removed, code excision only.

• Biopsies performed at the same/different Biopsies performed at the same/different sites of the same organ and without sites of the same organ and without removal, code only the biopsy once.removal, code only the biopsy once.

Endoscopy Guidelines Continued . . .Endoscopy Guidelines Continued . . .Endoscopy Guidelines Continued . . .Endoscopy Guidelines Continued . . .

• Biopsy performed and a different lesion Biopsy performed and a different lesion

is removed, code both the biopsy and the is removed, code both the biopsy and the

lesion excision. lesion excision.

• The code for excision cannot state “with” The code for excision cannot state “with”

or “without” biopsy. If this is listed, or “without” biopsy. If this is listed,

then the biopsy is not coded separately.then the biopsy is not coded separately.

• If multiple lesions are removed using If multiple lesions are removed using

different methods, code each method different methods, code each method

used separately with modifier –59.used separately with modifier –59.

• Biopsy performed and a different lesion Biopsy performed and a different lesion

is removed, code both the biopsy and the is removed, code both the biopsy and the

lesion excision. lesion excision.

• The code for excision cannot state “with” The code for excision cannot state “with”

or “without” biopsy. If this is listed, or “without” biopsy. If this is listed,

then the biopsy is not coded separately.then the biopsy is not coded separately.

• If multiple lesions are removed using If multiple lesions are removed using

different methods, code each method different methods, code each method

used separately with modifier –59.used separately with modifier –59.

Endoscopic Lesion Removal CodesEndoscopic Lesion Removal CodesEndoscopic Lesion Removal CodesEndoscopic Lesion Removal Codes

– No Documented Technique (45380)No Documented Technique (45380)

– Other Ablation Technique (45383)Other Ablation Technique (45383)

– Hot Biopsy Forceps (45384)Hot Biopsy Forceps (45384)• Monopolar and Bipolar Cautery

– Snare (45385)Snare (45385)

– No Documented Technique (45380)No Documented Technique (45380)

– Other Ablation Technique (45383)Other Ablation Technique (45383)

– Hot Biopsy Forceps (45384)Hot Biopsy Forceps (45384)• Monopolar and Bipolar Cautery

– Snare (45385)Snare (45385)

Definitions and Definitions and New CodesNew Codes

Definitions and Definitions and New CodesNew Codes

CPT CodesCPT CodesCPT CodesCPT Codes

– 0057T converted to 432570057T converted to 43257

– Upper GI endoscopy, including Upper GI endoscopy, including esophagus, stomach and either the esophagus, stomach and either the duodenum and or jejunum as duodenum and or jejunum as appropriate; with delivery of thermal appropriate; with delivery of thermal energy to the muscle of the lower energy to the muscle of the lower esophageal sphincter and/or gastric esophageal sphincter and/or gastric cardia, for treatment of GERDcardia, for treatment of GERD

• Called the Stretta procedure

– 0057T converted to 432570057T converted to 43257

– Upper GI endoscopy, including Upper GI endoscopy, including esophagus, stomach and either the esophagus, stomach and either the duodenum and or jejunum as duodenum and or jejunum as appropriate; with delivery of thermal appropriate; with delivery of thermal energy to the muscle of the lower energy to the muscle of the lower esophageal sphincter and/or gastric esophageal sphincter and/or gastric cardia, for treatment of GERDcardia, for treatment of GERD

• Called the Stretta procedure

New Codes In Bariatric SurgeryNew Codes In Bariatric SurgeryNew Codes In Bariatric SurgeryNew Codes In Bariatric Surgery

– 43644 – Laparoscopy, surgical, 43644 – Laparoscopy, surgical, gastric restrictive procedure; with gastric restrictive procedure; with gastric bypass and Roux-en-Y gastric bypass and Roux-en-Y gastroenterostomygastroenterostomy

– 43645 - … with gastric bypass and 43645 - … with gastric bypass and small intestine reconstruction to small intestine reconstruction to limit absorptionlimit absorption

– 43644 – Laparoscopy, surgical, 43644 – Laparoscopy, surgical, gastric restrictive procedure; with gastric restrictive procedure; with gastric bypass and Roux-en-Y gastric bypass and Roux-en-Y gastroenterostomygastroenterostomy

– 43645 - … with gastric bypass and 43645 - … with gastric bypass and small intestine reconstruction to small intestine reconstruction to limit absorptionlimit absorption

Parenteral NutritionParenteral NutritionParenteral NutritionParenteral Nutrition

• Nutritional supplementNutritional supplement

• Also called TPN (Total Parenteral Also called TPN (Total Parenteral Nutrition) or HyperalimentationNutrition) or Hyperalimentation

• Delivered intravenously Delivered intravenously

• GI tract is bypassed totallyGI tract is bypassed totally

• Liquid goes directly into the Liquid goes directly into the bloodstreambloodstream

• Nutritional supplementNutritional supplement

• Also called TPN (Total Parenteral Also called TPN (Total Parenteral Nutrition) or HyperalimentationNutrition) or Hyperalimentation

• Delivered intravenously Delivered intravenously

• GI tract is bypassed totallyGI tract is bypassed totally

• Liquid goes directly into the Liquid goes directly into the bloodstreambloodstream

Parenteral Nutrition Continued . . .Parenteral Nutrition Continued . . .Parenteral Nutrition Continued . . .Parenteral Nutrition Continued . . .

• CPT Codes:CPT Codes:– Infusion 90780 and the Infusion 90780 and the

appropriate number of hoursappropriate number of hours

• HCPCS Codes For Solutions and HCPCS Codes For Solutions and Supplies:Supplies:– B4164 – B5200B4164 – B5200

• CPT Codes:CPT Codes:– Infusion 90780 and the Infusion 90780 and the

appropriate number of hoursappropriate number of hours

• HCPCS Codes For Solutions and HCPCS Codes For Solutions and Supplies:Supplies:– B4164 – B5200B4164 – B5200

Enteral NutritionEnteral NutritionEnteral NutritionEnteral Nutrition

• Stomach is partially working, but Stomach is partially working, but cannot eat or absorb enough cannot eat or absorb enough nutrientsnutrients

• Taken in liquid form via feeding tubeTaken in liquid form via feeding tube

• Must go through part of GI tractMust go through part of GI tract

• Delivered directly into stomach or Delivered directly into stomach or intestinesintestines

• Stomach is partially working, but Stomach is partially working, but cannot eat or absorb enough cannot eat or absorb enough nutrientsnutrients

• Taken in liquid form via feeding tubeTaken in liquid form via feeding tube

• Must go through part of GI tractMust go through part of GI tract

• Delivered directly into stomach or Delivered directly into stomach or intestinesintestines

Enteral Nutrition Continued . . .Enteral Nutrition Continued . . . Enteral Nutrition Continued . . .Enteral Nutrition Continued . . .

• CPT Codes:CPT Codes:– 43752 feeding tube placement 43752 feeding tube placement

requiring physician skill; requiring physician skill; OROR

– 90799 if tube place and no 90799 if tube place and no physician skill was neededphysician skill was needed

• HCPCS Codes For Solutions and HCPCS Codes For Solutions and Supplies:Supplies:– B4034 - B4157B4034 - B4157

• CPT Codes:CPT Codes:– 43752 feeding tube placement 43752 feeding tube placement

requiring physician skill; requiring physician skill; OROR

– 90799 if tube place and no 90799 if tube place and no physician skill was neededphysician skill was needed

• HCPCS Codes For Solutions and HCPCS Codes For Solutions and Supplies:Supplies:– B4034 - B4157B4034 - B4157

Donor EnterectomyDonor Enterectomy(Intestinal Transplants)(Intestinal Transplants)

Donor EnterectomyDonor Enterectomy(Intestinal Transplants)(Intestinal Transplants)

• CPT Codes:CPT Codes:– 44132 - 4472144132 - 44721

– Clarifies the Clarifies the 33 components of components of physician workphysician work• Cadaver or Living Donor Enterectomy

• Backbench Work

• Recipient Intestinal Allotransplantation

• CPT Codes:CPT Codes:– 44132 - 4472144132 - 44721

– Clarifies the Clarifies the 33 components of components of physician workphysician work• Cadaver or Living Donor Enterectomy

• Backbench Work

• Recipient Intestinal Allotransplantation

American Society of Transplant American Society of Transplant Surgeons (ASTS) materialSurgeons (ASTS) material

American Society of Transplant American Society of Transplant Surgeons (ASTS) materialSurgeons (ASTS) material

• New Backbench Codes New Backbench Codes

• http://www.asts.org/Backbenchcodesmain.cfm

• This website contains much information This website contains much information on the utilization of transplant codes on the utilization of transplant codes and process. Highly recommend and process. Highly recommend reviewing too much to paste here!reviewing too much to paste here!

Billing for TransplantsBilling for TransplantsBilling for TransplantsBilling for Transplants

• Some of these codes may be new to 2005 and Some of these codes may be new to 2005 and hopefully you have charges in your charge hopefully you have charges in your charge file.file.

• If no charges, use the “no charge algorithm” If no charges, use the “no charge algorithm” to develop the transplant chargeto develop the transplant charge

• These procedures are fully billable but you These procedures are fully billable but you probably will need to have them pre-probably will need to have them pre-authorized through some insurance authorized through some insurance companies.companies.

• Some of these codes may be new to 2005 and Some of these codes may be new to 2005 and hopefully you have charges in your charge hopefully you have charges in your charge file.file.

• If no charges, use the “no charge algorithm” If no charges, use the “no charge algorithm” to develop the transplant chargeto develop the transplant charge

• These procedures are fully billable but you These procedures are fully billable but you probably will need to have them pre-probably will need to have them pre-authorized through some insurance authorized through some insurance companies.companies.

RectumRectumRectumRectum

• CPT Codes:CPT Codes:– 45391 and 4539245391 and 45392

• New codes to describe proximal New codes to describe proximal to splenic flexure flexible to splenic flexure flexible colonoscopy with endoscopic colonoscopy with endoscopic ultrasound examination ultrasound examination

• CPT Codes:CPT Codes:– 45391 and 4539245391 and 45392

• New codes to describe proximal New codes to describe proximal to splenic flexure flexible to splenic flexure flexible colonoscopy with endoscopic colonoscopy with endoscopic ultrasound examination ultrasound examination

AnusAnusAnusAnus

• HemorrhoidopexyHemorrhoidopexy– CPT Code: 46947CPT Code: 46947

– Method for coding repair of Method for coding repair of hemorrhoidal prolapse using hemorrhoidal prolapse using stapling techniquestapling technique

• HemorrhoidopexyHemorrhoidopexy– CPT Code: 46947CPT Code: 46947

– Method for coding repair of Method for coding repair of hemorrhoidal prolapse using hemorrhoidal prolapse using stapling techniquestapling technique

Screenings Colonoscopies & MedicareScreenings Colonoscopies & MedicareScreenings Colonoscopies & MedicareScreenings Colonoscopies & Medicare

• G Codes usedG Codes used– G0121 - Average Risk PatientsG0121 - Average Risk Patients

– G0105 - High Risk PatientsG0105 - High Risk Patients

Note: If a therapeutic procedure is Note: If a therapeutic procedure is performed during the screening performed during the screening procedure, use appropriate CPT procedure, use appropriate CPT Code and not the G code.Code and not the G code.

(CPT Assistant 1-04, Pages 4-5)(CPT Assistant 1-04, Pages 4-5)

• G Codes usedG Codes used– G0121 - Average Risk PatientsG0121 - Average Risk Patients

– G0105 - High Risk PatientsG0105 - High Risk Patients

Note: If a therapeutic procedure is Note: If a therapeutic procedure is performed during the screening performed during the screening procedure, use appropriate CPT procedure, use appropriate CPT Code and not the G code.Code and not the G code.

(CPT Assistant 1-04, Pages 4-5)(CPT Assistant 1-04, Pages 4-5)

Capsule EndoscopyCapsule EndoscopyCapsule EndoscopyCapsule Endoscopy

• CPT Code: 91110CPT Code: 91110– Capsule swallowedCapsule swallowed

– Moves thorough GI tractMoves thorough GI tract

– Transmits video signalsTransmits video signals

• CPT Code: 91110CPT Code: 91110– Capsule swallowedCapsule swallowed

– Moves thorough GI tractMoves thorough GI tract

– Transmits video signalsTransmits video signals

Modifiers, Modifiers, Modifiers, Modifiers, ModifiersModifiers

Modifiers, Modifiers, Modifiers, Modifiers, ModifiersModifiers

Procedures not completedProcedures not completedare still billable!are still billable!

Procedures not completedProcedures not completedare still billable!are still billable!

• Use of modifiers and Use of modifiers and sending sending documentationdocumentation will ensure will ensure reimbursement!reimbursement!

– 52 Reduced Services52 Reduced Services

– 53 Discontinued Procedure53 Discontinued Procedure

• Use of modifiers and Use of modifiers and sending sending documentationdocumentation will ensure will ensure reimbursement!reimbursement!

– 52 Reduced Services52 Reduced Services

– 53 Discontinued Procedure53 Discontinued Procedure

Incomplete Procedures Continued . . .Incomplete Procedures Continued . . .Incomplete Procedures Continued . . .Incomplete Procedures Continued . . .

-73-73 Discontinued Procedure – Discontinued Procedure – outpatient hospital, prior to the outpatient hospital, prior to the administration of anesthesiaadministration of anesthesia

-74-74 Discontinued Procedure – Discontinued Procedure – outpatient hospital, after the outpatient hospital, after the administration of anesthesiaadministration of anesthesia

-73-73 Discontinued Procedure – Discontinued Procedure – outpatient hospital, prior to the outpatient hospital, prior to the administration of anesthesiaadministration of anesthesia

-74-74 Discontinued Procedure – Discontinued Procedure – outpatient hospital, after the outpatient hospital, after the administration of anesthesiaadministration of anesthesia

Coding & BillingCoding & BillingScenariosScenarios

Coding & BillingCoding & BillingScenariosScenarios

Scenario 1 – Mouth & Throat Cancer (see handout)Scenario 1 – Mouth & Throat Cancer (see handout)Mr. Smith is admitted to the hospital with a diagnosis of mouth and throat cancer 145.9 and 149.0 . He has a glossectomy (define: Surgical removal of all or part of the tongue.) complete with tracheostomy with unilateral radical neck dissection (41145). A gastronomy, open with construction of gastric tube is also performed (43832). The supplies for the tracheostomy and g-tube are not separately billable for the inpatient portion @ this time. When Mr. Smith is discharged his trach supplies care kit (A4629), speaking valve (L8501) and other supplies in the range of A4623-A4628 may be covered based on carrier requirements. Mr. Smith’s g-tube is for feeling and if and when it needs changing (B4086) with g/j tubing. The enteral supplies such as the feeding supply kit are

in the B codes section.

Certification of medical necessity is required for coverage through most insurance companies. Depending on the method of delivery such as pump/gravity/syringe fed these are different kit codes. For example, gravity fed is B4036 for each day. Enteral nutrition is in calories per unit such as 100 cal=1 unit. If Mr. Smith is on an 800 calorie program he will receive 8 units per day. Mr. Smith is receiving blendarized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals and may include fiber (B4149).

Certification of medical necessity is required for coverage through most insurance companies. Depending on the method of delivery such as pump/gravity/syringe fed these are different kit codes. For example, gravity fed is B4036 for each day. Enteral nutrition is in calories per unit such as 100 cal=1 unit. If Mr. Smith is on an 800 calorie program he will receive 8 units per day. Mr. Smith is receiving blendarized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals and may include fiber (B4149).

Sample Billing codes and Sample Billing codes and ChargesCharges

Sample Billing codes and Sample Billing codes and ChargesCharges

HCPCS HCPCS codescodes

ChargeCharge UnitsUnits Total Total chargecharge

4114541145 1000.001000.00 11 1000.001000.00

4383243832 800.00800.00 11 800.00800.00

A4629A4629 55.0055.00 11 55.0055.00

L8501L8501 35.0035.00 11 35.0035.00

B4086B4086 45.0045.00 11 45.0045.00

B4149B4149 20.0020.00 88 160.00160.00

Scenario 2 – Abdominal & Digestive Disorders (see handout)Scenario 2 – Abdominal & Digestive Disorders (see handout)Mrs. Jones has a long history of abdominal and digestive disorders. She has GERD, diverticulitis, a bleeding ulcer. She is admitted from the ER to undergo a suture of the large intestine (colorrhapy) for perforated ulcer with colostomy (44605). [She also has 2 units of blood which we will not code here.] Post-operatively she receives all the necessary supplies and education to take care of her ostomy. Mrs. Jones has a non-Medicare primary insurance plan that reimburses for these supplies with a pre-certification call from the billing/UR office. She fills the RX in the pharmacy in 2 weeks for the following supplies: Skin barrier, 4x4 10 units (A4362), Adhesive remover (A4365) 1 unit, Ostomy pouches, drainable with faceplate attached 10 units (A4377) and Ostomy deodorant tablets 10 units (A4395). If Mrs. Jones had Medicare Primary and a supplemental/secondary plan it would also require a medical necessity form and the billing office could not bill electronically for these supplies.

Scenario 2 – Abdominal & Digestive Disorders (see handout)Scenario 2 – Abdominal & Digestive Disorders (see handout)Mrs. Jones has a long history of abdominal and digestive disorders. She has GERD, diverticulitis, a bleeding ulcer. She is admitted from the ER to undergo a suture of the large intestine (colorrhapy) for perforated ulcer with colostomy (44605). [She also has 2 units of blood which we will not code here.] Post-operatively she receives all the necessary supplies and education to take care of her ostomy. Mrs. Jones has a non-Medicare primary insurance plan that reimburses for these supplies with a pre-certification call from the billing/UR office. She fills the RX in the pharmacy in 2 weeks for the following supplies: Skin barrier, 4x4 10 units (A4362), Adhesive remover (A4365) 1 unit, Ostomy pouches, drainable with faceplate attached 10 units (A4377) and Ostomy deodorant tablets 10 units (A4395). If Mrs. Jones had Medicare Primary and a supplemental/secondary plan it would also require a medical necessity form and the billing office could not bill electronically for these supplies.

Sample Billing codes and Sample Billing codes and ChargesCharges

Sample Billing codes and Sample Billing codes and ChargesCharges

HCPCS HCPCS codescodes

ChargeCharge UnitsUnits Total Total chargecharge

4460544605 1000.001000.00 11 1000.001000.00

A4362A4362 2.002.00 1010 20.0020.00

A4365A4365 6.006.00 11 6.006.00

A4377A4377 15.0015.00 1010 150.00150.00

A4395A4395 1.001.00 1010 10.0010.00

Scenario 3 – Headache, Jaw Pain, Sleeping Problem Scenario 3 – Headache, Jaw Pain, Sleeping Problem (see (see handout)handout)Mr. Stanley presents with complaints of headache, jaw pain, difficulty sleeping and jaw locking. Other conditions are ruled out and the diagnosis is Temporal Mandibular Joint Disease (Disorder) TMJ. Mr. Stanley also has 2 non-erupted wisdom teeth that are contributing to the problem. Mr. Stanley is treated at the minor surgery wing of the dental suite at the medical center. First, the tow impacted teeth partially boney (D7230) are extracted with nitrous oxide for anesthesia. Next, a TMJ arthroscopy (D7874) with disc repositioning and stabilization is completed (see also 29804). Mr. Stanley is discharged late that day to his home with an RX for a surgical splint (D5988) which he picks up in the prosthetic department. Mr. Stanley has BCBS and Delta Dental for insurance. All items are to be sent to Delta Dental. If Mr. Stanley had Medicare primary, the procedure would be paid with Medicare prime but Medicare does not cover the splint so that is covered by Delta Dental as primary.

Scenario 3 – Headache, Jaw Pain, Sleeping Problem Scenario 3 – Headache, Jaw Pain, Sleeping Problem (see (see handout)handout)Mr. Stanley presents with complaints of headache, jaw pain, difficulty sleeping and jaw locking. Other conditions are ruled out and the diagnosis is Temporal Mandibular Joint Disease (Disorder) TMJ. Mr. Stanley also has 2 non-erupted wisdom teeth that are contributing to the problem. Mr. Stanley is treated at the minor surgery wing of the dental suite at the medical center. First, the tow impacted teeth partially boney (D7230) are extracted with nitrous oxide for anesthesia. Next, a TMJ arthroscopy (D7874) with disc repositioning and stabilization is completed (see also 29804). Mr. Stanley is discharged late that day to his home with an RX for a surgical splint (D5988) which he picks up in the prosthetic department. Mr. Stanley has BCBS and Delta Dental for insurance. All items are to be sent to Delta Dental. If Mr. Stanley had Medicare primary, the procedure would be paid with Medicare prime but Medicare does not cover the splint so that is covered by Delta Dental as primary.

Sample Billing codes and Sample Billing codes and ChargesCharges

Sample Billing codes and Sample Billing codes and ChargesCharges

HCPCS HCPCS codescodes

ChargeCharge UnitsUnits Total Total chargecharge

D7230D7230 500.00500.00 22 1000.001000.00

D7874D7874 1000.001000.00 11 1000.001000.00

29804*29804* 1000.001000.00 11 1000.001000.00

D5988D5988 100.00100.00 11 100.00100.00

ReferencesReferencesReferencesReferences

• Coding Clinic Coding Clinic

• CPT AssistantCPT Assistant

• CPT Changes 2005CPT Changes 2005

• ICD Changes 2005ICD Changes 2005• Faye Brown’s ICD Coding HandbookFaye Brown’s ICD Coding Handbook

• Coding Clinic Coding Clinic

• CPT AssistantCPT Assistant

• CPT Changes 2005CPT Changes 2005

• ICD Changes 2005ICD Changes 2005• Faye Brown’s ICD Coding HandbookFaye Brown’s ICD Coding Handbook

Continuing Education CreditContinuing Education CreditContinuing Education CreditContinuing Education Credit

• AHIMA – self report 1 hourAHIMA – self report 1 hour

• AAPC – AAPC – Preapproved for one hour Preapproved for one hour report report #DVAEES0505041119#DVAEES0505041119

• Reference: http://www.nutritioncare.org/homelink.asp?Link=www.nutritioncare.org/faq.html

Questions/Comments/ConcernsQuestions/Comments/ConcernsQuestions/Comments/ConcernsQuestions/Comments/Concerns

Denise.HamiltonDenise.Hamilton@@med.va.govmed.va.gov

Joletta.MaxileJoletta.Maxile@@med.va.govmed.va.gov

Vickie.NitschkeVickie.Nitschke@@mail.va.govmail.va.gov

Barbara.MillasBarbara.Millas@@med.va.govmed.va.gov

Denise.HamiltonDenise.Hamilton@@med.va.govmed.va.gov

Joletta.MaxileJoletta.Maxile@@med.va.govmed.va.gov

Vickie.NitschkeVickie.Nitschke@@mail.va.govmail.va.gov

Barbara.MillasBarbara.Millas@@med.va.govmed.va.gov