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From Registration to Accounts Receivable The Whole Can of Worms
2007 UBO/UBU
Conference
1
Briefing: MHS Coding Case Studies
Date: 20 March 2007
Time: 1610 - 1700
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Objectives
Make audience aware of migration from the UB-92 to
the UB-04 and its impact Contrast civilian coding conventions with those of the
MHS
Provide coding practice with real life scenarios
Highlight information from MHS Coding Guidelines
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MHS Coding Case Studies
Data Elements on the UB-04:
UB-04, Reason for Visit, Present on Admissionrevisions go into effect for the submission of claims 23
May 2007
A new UB-04 data element is the Present on Admission
(POA) indicator. Its purpose is to differentiate between
conditions present at admission and conditions that
develop during an inpatient admission
The Agency for Healthcare Research and Quality
(AHRQ) has stated that use of the POA indicator will
provide better outcomes for patient and improvehealthcare
Continued
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POA is defined as present at the time the order for
inpatient admission occurs. Conditions that developduring an outpatient encounter such as the initial
emergency department visit, or during observation are
considered as present on admission
The UB-04 revisions apply only to paper claimssubmissions. POA indicators apply to both principal
and secondary diagnoses fields
The reason for visit is required for all unscheduled
outpatient visits/bills with associated revenue codes45X, 516, 526
The reason for visit can have up to three ICD-9-CM
codes listed
MHS Coding Case Studies
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MHS Coding Case Studies
Case Study #1 POA
80-year-old female patient presents to the ED from thenursing home with a ever of 101.9, severe cough,
dehydration and difficulty breathing. Following her 5-
day hospital stay a,nd work up, the physician
documents the primary diagnosis as Small cellcarcinoma of the right lung. Is the small cell
carcinoma of the right lung a POA?
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MHS Coding Case Studies
Case Study #2 POA
52-year-old male is admitted for total hip replacementdue to complication from osteoarthritis. Following
surgery, he develops a pulmonary embolism. What
are the correct assignments for POA?
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MHS Coding Case Studies
Case Study #3 POA
62-year-old female is admitted from the physiciansoffice for a high fever and pneumonia. The patients
condition declines during her hospitalization and she
becomes septic according to the physician progress
notes. The physicians discharge summary listsSepsis as the primary diagnosis and Pneumonia as
a secondary diagnosis. What are the correct POA
assignments?
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MHS Coding Case Studies
Case Study #4 POA
21-year-old female is admitted to the hospital forinduction of labor at 42 weeks gestation, and
undergoes a normal delivery. What is the correct POA
assignment?
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MHS Coding Case Studies
Case Study #5 POA
25-year-old female is admitted to the hospital in activelabor. Following a normal delivery, the patient
develops a fever, high white blood cell count, and a
chest x-ray positive for pneumonia. What is the correct
POA assignment?
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MHS Coding Case Studies
Case Study #6 Reason for Visit
70-year-old male presents to the emergency room forshortness of breath and chest pain. Following
examination, he is discharged with a diagnosis of
musculoskeletal pain due to over exertion while
working in his garden. What is the reason for visit?
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MHS Coding Case Studies
Case Study #7 Reason for Visit
25-year-old female reports to the hospital-basedurgent care clinic for headache. Following
examination, she is discharged with a sinus infection.
What is the reason for visit?
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MHS Coding Case Studies
Case Study #8 Reason for Visit
A patient with a known history of asthma comes intothe emergency department (ED) complaining of
shortness of breath. The ED physician documents
Acute Asthma Exacerbation as the final diagnosis.
How would you code the reason for visit?
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MHS Coding Case Studies
Case Study #9 Emergency Department (ED)
A patient is seen in the emergency department with adiagnosis of ingestion of poison. The emergency
department physician performs gastric intubation,
aspiration, and lavage, and completes a detailed
history and comprehensive exam with high-complexitydecision making
As coder for the emergency department physician, you
assign the appropriate codes
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MHS Coding Case Studies
Case Study #10 ED
A patient was seen in the ED after cutting her fingerwith a paring knife. The provider sutures the 2.5 cm
laceration with a layered closure
According to the acuity level tool, this is a Level I
encounter What is the correct CPT code assignment for this
encounter?
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MHS Coding Case Studies
Case Study #11 ED
72-year-old Medicare patient presents to theemergency department for a 2.0 cm superficial
laceration of the upper arm, caused by a hoe in his
backyard garden. With the use of Dermabond tissue
adhesive, the provider approximated the wound edgesand dressed the wound
What are the correct code assignments?
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MHS Coding Case Studies
Case Study #12 ED
10-year-old boy was seen in the emergencydepartment after stepping on a piece of glass in the
public playground. The wound required prolonged
cleansing due to the amount of dirt and grass
embedded in the skin. A single-layer wound repairusing 6 stitches was performed. What are the correct
code assignments?
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MHS Coding Case Studies
Case Study #13 ED
Medicare patient presents to the emergencydepartment after falling down a flight of stairs. The
physician evaluates the patient's injuries: 2.0 cm
laceration of elbow, abrasions on the knee and
forearm. The patient explains that she felt dizzy beforethe fall, and the physician evaluates the problem. X-
rays and laboratory tests are normal. The physician
sutures the simple laceration
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MHS Coding Case Studies
Case Study #14 Clinic visit
A patient with an acute exacerbation of asthma is seenby family physician and has a detailed history taken;
an expanded, problem-focused, exam done; and low
level medical decision-making used. The patient
expresses a desire to quit smoking and receives 30minutes of initial treatment in a smoking cessation
program and a 1-week supply of nicotine gum. How is
this visit coded?
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MHS Coding Case Studies
Case Study # 15 Clinic visit
49-yr-old retired beneficiary has been evaluated over 3months (5 visits) for intermittent joint pain, intermittent
vertigo, and severe fatigue. Patient says he believes
he was exposed to something in Kuwait on mission
two years ago. Work-up to date is complete, butnegative
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MHS Coding Case Studies
Case Study #16 Clinic visit
S: This established 29-year-old patient of mine comes in today
because yesterday she was playing with her cat and the cat bit herleft forearm. She states she started feeling feverish and noticedincreased redness last night and this morning. She has had no jointpain with this
O: Temp 99.2 degrees, pulse 68, resp 20, weight 142. Left armreveals four puncture wounds with secondary cellulitis around the
area. The area is warm to the touch and is erythematous. A: Infected cat bite
P: The patient is put on Erythromycin 333 mg t.i.d. for 10 days andgiven 1 gram of Rocephin IV today. Follow up in 24 hours. Abandage was applied. The cat is up to date on his shots, and she
states that she had provoked the cat. Her last tetanus was over tenyears ago, so she was given a tetanus booster today. She will useTylenol as needed for pain
History: Expanded problem focused
Examination: Problem focused
Medical Decision Making: Moderate
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MHS Coding Case Studies
Case Study #17 Clinic visit
Clinic Progress Note, Eye Examination:
Today I saw Jay, who is now 21 years old. I last sawhim 6 years ago when he had a corneal ulcer on hisright eye. This is now cleared, and he has noticed thathe cannot see well
The patient has a normal corneal anterior chamberand iris but with very slow dilating pupils. There is nopseudoexfoliation, but there are dense juvenile nuclearcataracts on both eyes; the right greater than the left. Icounseled him for cataract surgery of this right eye
first, and then the left eye, the need for postopcorrection, a 4- to 6-week recovery time, and the typeof procedure; we will see him in surgery on the lastMonday of the month
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MHS Coding Case Studies
Case Study #18 Clinic visit
While chasing his brother, this 13-year-old male fellthrough a sliding glass door and sustained threelacerations: one on his left knee, one on his right knee,and one on his left hand
Left knee: 5.5 cm laceration involving deep subcutaneous
tissue and fascia, repaired with layered closure Right knee: 7.2 cm laceration repaired under local
anesthetic, with a single-layer closure
Left hand: 2.5 cm laceration of the dermis, repaired withsimple closure under local anesthetic
Assessment: Wounds of both knees and left hand requiresuture repair using 1% lidocaine for local anesthetic
Plan: Follow-up in 10 days for suture removal. Call office ifthere are any problems or complications
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MHS Coding Case Studies
Case Study #19 Clinic visit
An AD member who recently returned fromdeployment presents to clinic for an evaluation of a
rash. The provider evaluates the patient and
diagnoses the patient with cutaneous leishmaniasis
related to his recent deployment to Iraq The primary diagnosis?
The secondary code?
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MHS Coding Case Studies
Case Study #20 Clinic visit
Physical Therapy evaluation
Patient is referred to the local rehabilitation clinic by
family physician for a physical therapy evaluation after
a knee repair. Patient has degenerative osteoarthritis.
The physician provided the evaluation and a writtenreport was developed
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MHS Coding Case Studies
Case Study #21 Clinic visit
CC: Podiatry follow-up
S: The patient is a 46-year-old diabetic with complaints
of a painful foot. She neurologically has loss of feeling
that is consistent with neuropathy
O: She has an arthritic spur on the dorsum of the leftfoot which has been controlled in the past by trigger
point injection therapy. Here today for injection only
A: Arthritic exostosis and diabetic neuropathy
P: Trigger point injection of 1 cc of 0.5% Sensorcaineto the dorsum of the left foot done today
Will follow with PCP next week and return to me on
next episode of foot pain
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MHS Coding Case Studies
Case Study #22 Clinic or APV
LASIK
Pre-op:
Diagnosis 1: V72.83 Other Specified Pre-Op Exam
Diagnosis 2: Hypermetropia 367.0, Myopia 367.1,
Astigmatism 376.2, etc.
E&M 99499
Procedure Code(s) as applicable:
92004 Comprehensive New or 92014 Established
92015 Refraction (can only use once)
S0820 Computerized Corneal Topography (NewCPT code 92025 will be available in future
AHLTA upgrade)
76514 Pachymetry (no 50 modifier, bilateral code)
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MHS Coding Case Studies
Case Study #22 Clinic or APV
LASIK
Intra-operative: Diagnosis: Hypermetropia 367.0, Myopia 367.1,
Astigmatism 376.2, etc.
E&M 99499
Procedure Code(s) as applicable:S0800 LASIK
S0810 PRK Use 50 modifier for bilateral
Use 54 modifier only surgery performed at MTF
DO NOT use code 65760 Keratomileusis or 92070Therapeutic CL
99199 is performed as an APV
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MHS Coding Case Studies
Case Study #22 Clinic or APV
LASIK
Post-op: At same MTF:
Diagnosis 1: V67.09 Follow-up Examination, FollowingOther Surgery
Diagnosis 2: V45.69 Postsurgical State of the Eye and
Adnexa E&M: 99499
Procedure Code: 99024
At different MTF:
Diagnosis 1: V67.09 Follow-up Examination, Following
Other SurgeryDiagnosis 2: V45.69 Postsurgical State of the Eye andAdnexa
E&M: 99499
Procedure Code: S0800 or S0810 with 55 modifier forfirst f/u encounter, subsequent encounters 99024
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MHS Coding Case Studies
Case Study #23 Inpatient
Scenario: This 21-year-old gravida 1 para 1, bycesarean delivery, presented to the emergency
department in active labor. She was 38 weeks
gestation, visiting her parents 250 miles from her
home. Patient delivered vaginally in the elevator on the
way to obstetrics. The emergency services physician,
Dr. Scott, delivered the baby. An obstetrician, Dr. Dan,
delivered the placenta. The patient will follow up with
her obstetrician for postpartum care
A: What CPT code(s) should Dr. Scott report for thevaginal delivery?
B: In the above scenario, what CPT code(s) should Dr.
Dan use to report delivery of the placenta?
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MHS Coding Case Studies
Case Study #24 Inpatient
A patient is admitted for a scheduled cesarean section Preoperative Diagnosis: Previous C/S
Postoperative Diagnoses:
Previous C/S
Macrosomia Breech
Procedure performed: Repeat low transverse cesareansection
Findings: Viable infant male with Apgars of 8 and 9.The infants weight is 4206g. Maternal anatomynormal, including uterus, ovaries, and tubes. She didhave significant scarring and adhesions in thesubcutaneous tissue as well as subfascially
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MHS Coding Case Studies
Case Study #25 Inpatient
Patient with menorrhagia is admitted to GYN forplanned hysterectomy. Hysterectomy was performed
the day of admission. It was determined that uterine
fibroids were the cause of menorrhagia
Plannedadmission
w/out
complication
ICD-9 E/M CPT ResponsibleClinic
Day 1 Uterine fibroids 99499 Hysterectomy GYN
Day 2 Aftercare 99499 99024 GYN
Day 3 Aftercare 99499 99024 GYN
Discharge Aftercare 99499 99024 GYN
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MHS C di C St di
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MHS Coding Case Studies
Case Study #26 Inpatient
Patient was admitted to family practice with abdominal
pain. General surgery consulted on day 3 of admission
and determined a diagnosis of appendicitis. Care was
transferred to general surgery. On day 3, an
appendectomy was performed
Medical
condition
w/global
event
ICD-9 E&M CPT Responsible Clinic
Day 1 Abdominal Pain 9922199223 ~~ Family Practice
Day 2 Abdominal Pain 9923199233 ~~ Family Practice
Day 3 Appendicitis 9925199255-57 Appendectomy General Surgery
Discharge Aftercare 99499 99024 General Surgery
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Q i
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When is POA defined?
A civilian ED encounter does not require an E&M codeunder what circumstances?
LASIK is coded using what type of code?
Does the MHS use global OB codes?
Rounds are considered what type of services?