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Ken Fan, Consultant,

Dubai Health Insurance Corporation

DHA

Disclaimer

2

This document has been created by or on behalf of the Dubai Health Authority (DHA). It may only be accessed, downloaded and used by Providers and Payers within the Insurance System for Advancing Healthcare in Dubai (ISAHD) network or those intending to enroll in the ISAHD network, and subcontractors of the DHA (each an Authorized User) as part of the ISAHD’s work in the Emirate of Dubai. No other individual or organization may access, download or use it without prior consent from the DHA.

The DHA is the owner or licensee of all intellectual property rights in this document, and this document is protected by copyright laws and treaties around the world. All such rights are reserved.

If the documentation or any information contained within it is used or relied upon by any person other than an Authorized User or by an Authorized User for any reason otherwise than for which it was intended, neither the DHA nor their representatives or agents will be held liable for any loss or damage arising out of such use or reliance, whether foreseeable or not. Unauthorized use may also result in the DHA taking legal action, including bringing claims for damages based on the unauthorized use.

The DHA makes no representations, warranties or guarantees of any kind whether express or implied that the content of this document is accurate, complete or up-to-date. To the extent permitted by law, we exclude all conditions, warranties, representations or other terms which may apply to this document, whether express or implied.

This disclaimer is of immediate effect from the time this document is published.

Workshop Agenda

3

• Full Implementation Refresher – DRG Payment Parameters

• DRG Reporting Guidelines for eClaimlink

• Medical Coding and Code Sets

• Q&A

DRG Refresher - Overview

4

• The DRG payment system uses a series of parameters for calculating the specific payments to be made to hospitals for each inpatient stay.

Full Implementation DRG Parameters

Base RateRelative Weights

Outlier Payment

Components

Negotiation Band

Transfer Payments

Add-On Payment

Components

DRG Refresher - Parameters

5

• The base rate represents the DRG payment for the overall “average” hospital inpatient admission.

o Adjusted for budget neutrality & normalized to allow for negotiation

• Relative weights adjust the base rate for changes in the resources required to provide different hospital services as measured by the DRGs.

• Calculated by 3M using the claimed amounts in the Dubai claims data and supplemental information from Abu Dhabi.

BaseRate =Total Payments for all Inpatient Cases

Case − Mix Adjusted Number of Cases


6

• The purpose of outlier payments in the DRG payment system is to provide risk sharing for very costly cases.

o Outlier Payment Components

Target percentage of payments that are outlier payments (TPOP)

Claim cost

Marginal

Threshold

• Imputing Claim Cost

• A predetermined cost for each activity code times the total number of activities billed on the claim


7

• The negotiation band is the range within which health insurance companies and individual hospitals are permitted to negotiate the base rate.

o One negotiation factor is allowed per hospital/insurer combination

• Hospitals sometimes transfer patients to other hospitals

o Transfer payments allow for both hospitals treating the patient to be paid fairly for the care provided.

o Transfers of inpatients within a hospital system, where both the transferring hospital and the receiving hospital are owned by the same company, will not receive a transfer payment; only the DRG payment will be made.

Updated Transfer Payments

8

• Hospitals sometimes transfer patients to other hospitals

• Payment to hospitals transferring patients to other hospitals will be a graduated per diem payment • The first hospital day will be paid the full per diem rate

• Subsequent hospital days will be paid 50% of the per diem rate.

• The per diem rate = DRG inlier payment calculated using the hospital/insurer specific negotiation factor divided by average length of stay.

Updated Transfer Payments

9

• The maximum payment for any case for a patient transferred to another hospital will be the DRG inlier payment calculated with the hospital/insurer specific negotiation factor for the DRG for that hospital case.

• The receiving hospital will be paid the regular DRG payment

• Transfers of inpatients within a hospital system, where both the transferring hospital and the receiving hospital are owned by the same company, will not receive a transfer payment; only the DRG payment will be made.

High Cost Consumable and Drug Add-On Payments

11

• Criteria for Add-On Eligibility:

o The device or drug is on the established Dubai high cost list.

o The total cost of the specified device or drug for the claim is AED 5,000 or greater.

o The cost of the specified device or drug exceeds the specific HCPCS or drug portion of the DRG payment.

o Calculated as the inlier payment after negotiation times the HCPCS or drug DRG-specific percentage standard payment

High Cost Consumables List

12

HCPCS Code Description

A4649 Surgical supply; miscellaneous. Eligible only for individual items with cost of 5000 AED or greater.

C1713 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone implantable

C1721 Cardioverter-defibrillator, dual chamber implantable

C1722 Cardioverter-defibrillator, single chamber implantable

C1731 Catheter, electrophysiology, diagnostic, other than 3D mapping 20 or more electrodes

C1732 Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping

C1776 Joint device implantable

C1781 Mesh implantable

C1785 Pacemaker, dual chamber, rate-responsive implantable

C1786 Pacemaker, single chamber, rate-responsive implantable

C1789 Prosthesis, breast implantable

C1817 Septal defect implant system, intracardiac

C1821 Interspinous process distraction device implantable

C1874 Stent, coated/covered, with delivery system

C1875 Stent, coated/covered, without delivery system

C1876 Stent, non-coated/non-covered, with delivery system

E0601 Continuous airway pressure CPAP device

E0616 Implantable cardiac event recorder with memory, activator and programmer

G0290Transcatheter placement of a drug eluting intracoronary stents, percutaneous, with or without other therapeutic

intervention, any method; single vessel

L1932Ankle foot orthosis AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting

and adjustment

L8614 Cochlear device, includes all internal and external components

S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components

13

High Cost Drug List

26 Scientific Codes that map to 45 DDCs.

Scientific Code Scientific name Scientific Code Scientific name

101301-113 Paclitaxel: 100 mg Suspension for Injection 219701-080 Tenecteplase: 40 mg Powder for Injection

104301-049 Alteplase: 50 mg Infusion 219702-080 Tenecteplase: 10000 Iu Powder for Injection

111301-078Pemetrexed As Disodium Heptahydrate: 500 mg Powder

for Infusion231703-102 Pegfilgrastim: 6 mg/0.6ml Solution for Injection

126402-013 Bevacizumab: 400 mg/16ml Concentrate for Infusion 235404-080 Coagulation Factor VIIa: 1 mg Powder for Injection

176302-014Cetuximab: 5 mg/ml Concentrate for Solution for

Infusion258101-080 Infliximab: 100 mg Powder for Injection

183801-100Human Immunoglobulin: 50 mg/ml Solution for

Infusion259204-145 Lenalidomide: 25 mg Capsules Hard Gelatin

183802-100Human Immunoglobulin: 100 mg/ml Solution for

Infusion274501-013 Docetaxel: 80 mg Concentrate for Infusion

183808-100Human Immunoglobulin: 5 G/100ml Solution for

Infusion274503-013 Docetaxel: 10 mg/ml Concentrate for Infusion

195701-078 Trastuzumab: 440mg Powder for Infusion 283401-039 Valganciclovir As HCL: 450 mg Film Coated Tablets

197503-102 Adalimumab: 40 mg/0.8ml Solution for Injection 285801-013 Panitumumab: 20 mg/ml Concentrate for Infusion

202409-100Human Normal Immunoglobulin Igg, Iga: 100 mg/ml

Solution for Infusion290701-078 Trabectedin: 1 mg Powder for Infusion

214502-102 Ranibizumab: 10 mg/ml Solution for Injection 538701-102 Aflibercept: 40 mg/ml Solution for Injection

215502-013 Rituximab: 500 mg/50ml Concentrate for Infusion 580801-078 Carfilzomib: 60 mg Powder for Infusion


14

• For devices and drugs meeting the criteria the add-on payment is 75% of the difference between the documented invoice cost and the HCPCS or drug portion amount built into the DRG payment.

• Hospitals will need to receive prior authorization from the health insurance company and submit invoices to document the amount paid for the high cost device or drug with the submission of the claim.

• Hospitals must also maintain documentation to support the clinical justification for use of the high cost consumable or drug.


15

• Example Calculation

DRG: 146102

DRG Name: IP CESAREAN DELIVERY W/CC

HCPCS Portion of Payment (%): 8.736%

Inlier Payment following Negotiation (AED): 23,302.95

HCPCS Portion of Inlier Payment (AED): 2035.75

Total Reported Cost of High Cost HCPCS (AED): 6,000

Add on Payment; 75% X (6,000 – 2,035.75) (AED): 2,973.19


16

• Inclusion of add-on payments changes the outlier formula:

Shadow Billing Formula

60% ∗ (𝐶𝑜𝑠𝑡 − 𝐼𝑛𝑙𝑖𝑒𝑟 𝑃𝑎𝑦𝑚𝑒𝑛𝑡 − 𝑇ℎ𝑟𝑒𝑠ℎ𝑜𝑙𝑑)

Full Implementation Formula

60% ∗ (𝐶𝑜𝑠𝑡 − 𝐼𝑛𝑙𝑖𝑒𝑟 𝑃𝑎𝑦𝑚𝑒𝑛𝑡 − 𝐻𝑖𝑔ℎ 𝐶𝑜𝑠𝑡 𝐴𝑑𝑑−𝑂𝑛 𝑃𝑎𝑦𝑚𝑒𝑛𝑡𝑠 − 𝑇ℎ𝑟𝑒𝑠ℎ𝑜𝑙𝑑)

Dubai DRG Parameters for Full Implementation

17

Mandatory Fields

18

• Emirates ID• DOB and Gender• Admission and Discharge Date/Time• Patient Share• Patient Weight for Neonates• Present on Admission (PoA)

Data Issues

19

• Outpatient clinics submitting hospital admitted cases (inpatient andday-patient claims)

• Submit and validate mandated codes and code sets only

Sabine Karam23 February, 2020

Shadow Billing Phase of DRG Project

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• Observation codes of type “Financial” used for reporting DRG Payment Parameters on the DRG Activity level in all inpatient ClaimSubmissions where EncounterType = 3 or 4:

DRGTotalPayment

DRGInlierPayment

DRGOutlierPayment

DRGTransferPayment

• DRG Activity Net Amount must = 0

• All other Activities must be reported following fee-for-service model where Net Amount = value to be claimed from the payer for each activity.

These will no longer be applicable during the go-live implementation phase

Go-Live Implementation Phase of DRG Project

22

DRG Payment Parameters to be reported separately on different activity lines:

*All items marked with Asterix are new codes on the Dubai Service List (DSL)

Activity Type Activity Code Used for Reporting of:

9 - DRG DRG Code DRG Inlier Payment

8 - DSL 99* DRG Outlier Payment

8 - DSL 99.01* DRG Transfer Payment

8 - DSL 98* DRG Add-On Payment for High Cost Consumables

8 - DSL 98.01* DRG Add-On Payment for High Cost Drugs

DRG Payment Parameters

23

Inlier Payment (DRG Activity):

• The DRG activity claimed amount should reflect the contracted DRG Inlier claim amount

Outlier Payment:

• If outlier payment applies,

use DSL Code 99 to report the DRG Outlier Payment

Transfer Payment:

• For Transfer cases,

use DSL Code 99.01 to report the DRG Transfer Payment

DRG Payment Parameters

24

High Cost Consumables and Drugs

• High cost HCPCS/DDC codes should be reported with ActivityNet = 0

• The following observation codes must be included:

ActivityCost– New financial observation to be used for reporting the actual cost value for each high cost activity

File Attachment – PDF attachment of Invoice/Receipt, to be submitted as proof of the activity cost

In case the above observation values are not reported for high cost activities, then the Payer should reject the activity using denial code DRG-005 - Missing Observation

Add-On Payments for High Cost Activities

• Add-on payments can be reported using the new Dubai Service List Codes:

98 – DRG Add-On Payment for High Cost Consumables

98.01 - DRG Add-On Payment for High Cost Drugs

Key Highlights

25

Financial Amounts on the Claim Level

• Providers must accurately report the Gross, Net and Patient Share amounts on the claim level, depending on the tariff plan agreed with the payer

• The claim-level reported financial amounts should reflect the total DRG Payment

ClaimGross Value = Total DRG Payment

Financial Amounts on the Activity Level for All DRG Payment Parameters

• Providers must use ActivityNet to report the amount requested from the Payer for each payment parameter

All performed activities that are non-DRG Payment Parameters

• Must be reported in the claim

• With ActivityNet = 0

If Providers fail to report all performed activities, then the Payer should reject the claim using denial code

• DRG004 – Missing Activities

Denial Codes

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Denial Code Description Existing /New Notes

PRCE-001Calculation

DiscrepancyExisting

Use for denying activity line if amount requested is incorrect. Can

be used for DRG Inlier payment, outlier payment, transfer payment,

add-on payment for high cost consumable/drug, and for activity

Cost.

Use in case the tallying of the DRG Activities Amount is incorrect.

DRG-001Incorrect DRG

codeNew

DRG-002Missing DRG

codeNew

DRG-003Incorrect Billing

RegimeNew

Use in case provider submits fee for service billing/ does not follow

the DRG Payment Model.

DRG-004 Missing Activities NewUse for denying the claim if not all performed activities are reported

in the claim.

COPY-002Incorrect Patient

ShareNew

COPY-003Missing Patient

ShareNew

Use in case the provider does not report the patient share amount

on the claim.

DRG-005

Missing

Observation

(ActivityCost

and/or File

Attachment)

New

Use to reject the activity if it is a high cost consumable or drug and

is missing the required observations: ActivityCost and/or Invoice

PDF attachment.

Sample Claim - Contains Arbitrary Activity Codes and Values for Demonstration Purpose – not clinically valid

27

Claim

ClaimGross ClaimNet ClaimPatient Share

50000 45000 5000

Diagnosis

Type Code DxInfoType DxInfoCode

Primary I25110 POA Y

Secondary I10 POA Y

Secondary E785 POA Y

Activities

Activity ID Activity Type Activity CodeActivityQuantit

yActivityNet Observation1 Observation2

1 9 - DRG 051051 1 27000Risk of Mortality

1

2 8 - DSL 99 - Outlier 1 9000

3 8 - DSL *98 - Add-on HCPCS 1 4500

4 8 - DSL *98.01 - Add-0n Drug 1 4500

5 8 – DSL 65 1 0

6 8 – DSL 20 1 0

7 3 - CPT 33533 1 0

8 5 - DDC 0006-106601-0391 1 0

9 4 - HCPCS A4930 1 0

10 4 - **HCPCS A4649 1 0ActivityCost*

10,000File Attachment of Invoice

11 5 - **DDC 0013-101301-1131 1 0ActivityCost*

10,000File Attachment of Invoice

Sample Claim - Transfer Cases

28

Claim

ClaimGross ClaimNet ClaimPatient Share

15000 13500 1500

Diagnosis

Type Code DxInfoType DxInfoCode

Primary I25110 POA Y

Secondary I10 POA Y

Secondary E785 POA Y

Activities

Activity ID Activity Type Activity CodeActivityQuantit

yActivityNet Observation1 Observation2

1 9 - DRG 051051 1 0Risk of Mortality

1

2 8 - DSL **99.01 – Transfer** 1 13500

3 3 - CPT 33533 1 0

4 5 - DDC 0006-106601-0391 1 0

5 4 - HCPCS A4930 1 0

Sample Claim

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* Newly introduced activity and observation codes

** The transfer payment to be reported should be a graduated per diem payment. The first hospital day will be paid the full per diem rate. Subsequent hospital days will be paid 50% of the per diem rate. In the ClaimSubmission, the provider should report one transfer payment by calculating the sum of per diem daily rates.

Full details on the transfer payment guidelines

• DRG Full Implementation Presentation

https://www.eclaimlink.ae/docs/DRG%20Guidelines%20Full%20Implementation.pdf

Documentation – DHD

30

Dubai Service List (DSL)

• Documentation > Codes and Lists > Dubai Service List

Observation reporting details

• Documentation > eClaimLink Observation Details Release 2019 -02-12

Reporting Samples - ClaimSubmission xml files

• A sample submission containing a DRG activity and its associated attributes

• A sample submission for a transfer case

All DRG Project Documents and Presentations

• DHD > Documentation

DRG Full Implementation

DRG Shadow Billing Phases I & II

https://www.eclaimlink.ae/dhd_codes.aspx

https://www.eclaimlink.ae/docs/eClaimLink%20Observation%20Details%20Release%2020190212.pdf

https://www.eclaimlink.ae/docs/Claim_Submission_with_DRG_Sample_20200211.xml

https://www.eclaimlink.ae/docs/Claim_Submission_with_DRG_Transfer_Sample_20200211.xml

https://www.eclaimlink.ae/dhd_documentation.aspx

Review of Dubai Medical Code Sets

32

Upgrade to 2018 Version with effect from 1 April 2020

Dubai Medical Coding Manual

33

Development Process

Timeline Draft Progress

Dec 2017 1st Presented at 3rd DMCTF Meeting. Collected feedback

May 2018 2nd Includes DMCTF feedback

Oct 2018 3rd Presented 4th DMCTF Meeting. DMCTF Consensus

Apr 2019 Final Promulgations Sessions

Sep 2019 Final DHA Mandate

In claims submission:• Providers to code according to the coding standards• Payers to adjudicate according to the coding standards

3M CodeFinder / Grouper Software Mandate

34

Providers:• All DHA and DHCC licensed facilities with inpatient activities

Payers:• All Insurance companies / TPAs that adjudicate inpatient claims

Presented By:

Anita Kangat CPC-I RHIT CHIM CCS CCS-P CPMA CPC

Regional Director-AAPC

AAPC

• Largest trade association in the world for healthcare business

professionals in medical auditing, coding and billing.

• Leading credentialing authority in health information management with

over 30 certifications recognized as industry gold standards and

accepted world-wide by employers, payers, providers and regulators.

• With over 185,000 global members, AAPC has the most extensive

network of HIM professionals enabling us bring the right mix of skills,

experience and expertise to any project around the world.

• Strong leadership with a global advisory board of over 50 nationally

recognized industry leaders and experts in medical coding and

auditing

• Comprehensive solution offerings including training, certifications,

continuing education, software, and CDI programs.

Founded1988

OfficesUnited States

India

Philippines

UAE

Membership185,000

Net Promoter Score85

National Advisory Board50+

COMPANY OVERVIEW KEY HIGHLIGHTS

Information on this slide is copyrighted by AAPC and may not be used without express permission from AAPC

AAPC OVERVIEW

AAPC is an international leader in CDI programs and physician training

AAPC has a global team conducting audit and education work for organizations

throughout the world.

AAPC has assisted over 800 clients in clinical documentation improvement

initiatives.

Trained over 50,000 physicians on clinical documentation improvement.

Conducts over 2000 medical audits annually

Providers

Payers

BPOs


AAPC OVERVIEWMarket Leader in Professional Services

As a leading authority in Health Information and Revenue Cycle Management, AAPC brings deep expertise to support

businesses with our professional service offerings. AAPC would be happy to furnish any additional information on below

services upon request.

CERTIFICATION

Professional Credentialing

HiTRUST Certification

NIST 800-53 Certification

PCI-DSS Certification

TRAINING

Certification Preparations

2018 Code Set Changes

DRG Vs CMI

Post Audit Remedial

AUDITING

Compliance Audits

Special Investigations

Auditing Software

Program Development

COMPLIANCE

Program Development

IT Effectiveness

Vulnerability Management

Corp Integrity Agreements

MEDICAL CODING

Offsite Coding

Onsite Coding

Management Support

Program Development

REVENUE CYCLE

Optimization Review

Underpayment Recovery

Program and Process Development



Transition to 2018

• General coding guideline changes• Chapter specific guideline changes• Code changes

Overall Impact of The Transition


CPT Code Changes

• 1,376 New Codes Added

• 567 Codes Revised

• 496 Codes Deleted

ICD-CM Code Changes

• 4,677 New Codes Added

• 651 Codes Revised

• 453 Codes Deleted


ICD-10-CM

ICD10CM-Excludes Includes Notes


Includes Notes This note appears immediately under a three-character code title to further define, or give examples of, the content of the category

Excludes1 A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2 A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

ICD10CM-Transition Changes




WAS IS

3) Diabetes mellitus and the use of insulin and oral

hypoglycemics

If the documentation in a medical record does not indicate the

type of diabetes but does indicate that the patient uses insulin,

code E11-, Type 2 diabetes mellitus, should be assigned. An

additional code should be assigned from category Z79 to identify

the long-term (current) use of insulin or oral hypoglycemic drugs. If

the patient is treated with both oral medications and insulin, only

the code for long-term (current) use of insulin should be assigned.

Code Z79.4 should not be assigned if insulin is given temporarily

to bring a type 2 patient’s blood sugar under control during an

encounter.

3) Diabetes mellitus and the use of insulin

If the documentation in a medical record does not indicate the

type of diabetes but does indicate that the patient uses insulin,

code E11, Type 2 diabetes mellitus, should be assigned. Code

Z79.4, Long-term (current) use of insulin, should also be

assigned to indicate that the patient uses insulin. Code Z79.4

should not be assigned if insulin is given temporarily to bring a

type 2 patient’s blood sugar under control during an encounter.



E11.1 Type 2 diabetes mellitus with ketoacidosis

• E11.10 Type 2 diabetes mellitus with ketoacidosis without coma

• E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

E78.00 Pure hypercholesterolemia

• (Pure) hypercholesterolemia NOS

b. Blindness

If “blindness” or “low vision” of both eyes isdocumented but the visual impairment categoryis not documented, assign code H54.3,Unqualified visual loss, both eyes. If “blindness”or “low vision” in one eye is documented but thevisual impairment category is not documented,assign a code from H54.6-, Unqualified visual loss,one eye. If “blindness” or “visual loss” isdocumented without any information aboutwhether one or both eyes are affected, assigncode H54.7, Unspecified visual loss.

H42 Glaucoma in diseases classified elsewhere

• Code first glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39)

• Deleted the Excludes2: glaucoma (in diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39)



1) Hypertension with Heart Disease

Heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11,Hypertensive heart disease, when a causalrelationship is stated (due to hypertension) orimplied (hypertensive). Use an additional codefrom category I50, Heart failure, to identify thetype of heart failure in those patients with heartfailure.

The same heart conditions (I50.-, I51.4-I51.9)with hypertension, but without a stated causalrelationship, are coded separately. Sequenceaccording to the circumstances of theadmission/encounter.

1) Hypertension with Heart Disease

Hypertension with heart conditions classifiedto I50.- or I51.4- I51.9, are assigned to a code fromcategory I11, Hypertensive heart disease. Useadditional code(s) from category I50, Heart failure,to identify the type(s) of heart failure in thosepatients with heart failure.

The same heart conditions (I50.-, I51.4-I51.9)with hypertension are coded separately if theprovider has specifically documented a differentcause. Sequence according to the circumstances ofthe admission/encounter.

ICD-10-CM - Case Examples


What codes, according to ICD-10-CM guidelines,

describe a patient that has hypertension with left heart

failure?

a. I10, I50.1 c. I11.9, I50.1

b. I11.0, I50.1 d. I50.1, I11.0

A patient is being treated for ketoacidosis and diabetic

coma due to malignant neoplasm of the pancreatic

body. The patient uses insulin routinely. What ICD-10-

CM codes are reported?a. E13.11, C25.1 c. C25.1, E08.11, Z79.4

b. E10.11, C25.2, Z79.4 d. C25.9, E08.11

The patient has a significant visual impairment(category 2) due to astigmatism in the left eye. It iscorrected with glasses. The right eye has normalvision. What ICD-10-CM code(s) is/are reported?

a. H54.7, H52.202 c. H54.7

b. H52.202, H54.52A2 d. H52.212

According to ICD-10-CM guidelines, when a patient is

seen for management of anemia due to malignancy, how

is it reported?

a. Anemia is the only condition reported.

b. The malignancy is the only condition reported.

c. The malignancy is reported first, followed by the code

for the anemia.

d. Anemia is reported first, followed by the code for the

malignancy.

CPT


Integumentary


10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma,

lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

• Do not report imaging separately

• Report one unit of 10030 for each separate catheter

• Includes moderate sedation

10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle,

radioactive seeds), percutaneous, including imaging guidance; first lesion

+10036 … each additional lesion (List separately in addition to code for primary procedure)

Integumentary – Case Example


A physician diagnosed a 54-year-old female patient with adenocarcinoma of the axillary lymph node that hasmetastasized from breast cancer of her left breast. She is taken to the surgical suite for placement of apercutaneous placement of a fiducial marker in the left axillary lymph node.

A physician diagnosed a 54-year-old female patient with adenocarcinoma of the axillary lymph node that hasmetastasized from breast cancer of her left breast. She is taken to the surgical suite for placement of apercutaneous placement of a fiducial marker in the left axillary lymph node.

CPT: 10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion

ICD-10-CM:

C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes

C50.912 Malignant neoplasm of unspecified site of left female breast

If history of breast cancer: report Z85.3 instead of C50.912

New Burn Classification Chart


1. A new illustration and table for determining the total body surface

area for treatment of burns (16000-16036) is added

2. The Lund-Browder classification method takes into consideration

the body surface area of patients of different ages

3. An easy-to-use table is included that provides the total body

surface area by anatomic site and patient age

Musculoskeletal


20600, 20605, 20610 revised: without ultrasound guidance

20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound

guidance, with permanent recording and reporting

20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular,

acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent

recording and reporting

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial

bursa); with ultrasound guidance, with permanent recording and reporting

Musculoskeletal – Case Example


PREOPERATIVE DIAGNOSIS: Chronic lower back pain and right trochanteric bursitis.

POSTOPERATIVE DIAGNOSIS: Chronic lower back pain and right trochanteric bursitis.

OPERATION PERFORMED: Right trochanteric bursa injection under fluoroscopy.

ANESTHESIA: Local.

INDICATIONS: This is a 42-year-old pleasant lady who is known to us at the Pain Clinic. The patient was evaluated,diagnosed with chronic bursitis. The patient is scheduled for the above mentioned procedure. The procedure wasexplained, risks and benefits were discussed. Patient agreed to proceed.

DESCRIPTION OF PROCEDURE: The patient was identified. The procedure was explained. Informed consent was obtained.The patient was then taken to the block room, put in the prone position. The area over the right trochanteric bursa wasprepped and draped in the usual sterile fashion using Betadine solution. Under fluoroscopic guidance the trochantericbursa right side was identified. Skin and subcutaneous tissue infiltrated with 5 cc of 1-% lidocaine using a 25-gaugeneedle. Using a 22-gauge spinal needle introduced into the trochanteric bursa under fluoroscopy and a total volume of 8cc of normal saline and 40 mg of Kenalog was injected under fluoroscopy. Needle removed. Skin puncture covered withBand-Aid. Patient tolerated the procedure without complication. The patient was then taken to the post block room forobservation in stable condition. The patient was then discharged home with instructions after meeting discharge criteria.

Musculoskeletal


• Type of joint injected: Major

• Imaging guidance fluoroscopy.

• Correct procedure codes:

20610-RT Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee,

subacromial bursa); without ultrasound guidance

77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

(List separately in addition to code for primary procedure)

Cardiovascular


WAS

37215 Transcatheter placement of intravascular stent(s), cervical carotid artery,

percutaneous, with distal embolic protection

IS

37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, open or

percutaneous, including angioplasty, when performed, and radiological supervision and

interpretation; with distal embolic protection

Cardiovascular - Case Example


DESCRIPTION OF RIGHT PROXIMAL CERVICAL INTERNAL CAROTID ARTERY PERCUTANEOUS TRANSLUMINALANGIOPLASTY AND STENT PROCEDURE:For the stent procedure, a 6 French shuttle sheath was placed in theright femoral artery and advanced over a JB1 catheter and a Supracore wire to the distal right common carotidartery. Angiomax was administered and Plavix 150 mg was administered in addition to the patient’s usualdaily dose. The right internal carotid artery was then approached with the Accunet 7.5 mm filter wire whichwas successfully deployed in the right internal carotid artery. Balloon dilatation was performed with a 3.0mm balloon at this point. The 7 to 10 x 40 tapered stent was then deployed over a Stabilizer Plus wire. Thestent was then post dilated with 5.5 mm Aviator balloon to 8 atmospheres. This provided an excellentangiographic result and there was no evidence of distal embolization. The filter wire was then captured andremoved. Final intracranial view showed normal intracranial circulation in the AP and lateral views with noresidual stenosis of the proximal internal carotid stenosis.

Correct Code:

37215-RT Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous,including angioplasty, when performed, and radiological supervision and interpretation; with distal embolicprotection

Digestive


WAS

43202 Esophagoscopy, rigid or flexible; with biopsy single or multiple

43215 Esophagoscopy, rigid or flexible; with removal of foreign body(s)

IS

43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple

43215 Esophagoscopy, flexible, transoral; with removal of foreign body(s)

Digestive – Case Example


After informed consent was obtained, the patient was sedated in the upright position with 100 ml Demerol and 5 of Versed. The

Olympus endoscope was passed under direct visualization into the esophagus. There was a large food bolus and a significant amount

of fluid stuck. This was removed through the suction catheter as well as pushed distally into the stomach. The patient did also vomit.

His esophagus was completely clear of food and residual matter. The lower esophageal sphincter was at approximately 42 cm. The

entire esophagus had linear streaking with focal nodularity throughout. It was worse in the lower third of the esophagus than in the

proximal third. His gastric lumen was inspected and there was no ulceration or friability and there was no evidence of a hiatal hernia.

The LES was patulous. Biopsies of the lower esophagus and proximal esophagus were obtained and labeled separately. The patient

was transferred to post-op anesthesia recovery unit breathing spontaneously. There were no immediate complications.

Definitive plans will be made pending biopsy results. This young man will either need to be on a proton pump inhibitor or topical

steroid therapy for EE. There were no immediate complications.

Correct Codes:

43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple

43215 Esophagoscopy, flexible, transoral; with removal of foreign body(s)

Urinary


WAS 2 codes

52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy(ureteral catheterization is included)

52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

IS 1 Combination code

52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

Nervous


Codes 62310, 62311, 62318, and 62319 were deleted

62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic,antispasmodic, opioid, steroid, other solution), not including neurolytic substances,including needle or catheter placement, interlaminar epidural or subarachnoid, lumbaror sacral (caudal); without imaging guidance

62323 with imaging guidance (ie, fluoroscopy or CT)

Sense Organs - Case Example


WAS

69210 Removal impacted cerumen(separate procedure), 1 or both ears

IS

69210 Removal impacted cerumen requiring instrumentation, unilateral

(For bilateral procedure, report 69210 with modifier 50)

Sense Organs – Case Example


ENMT: Impacted cerumen in canals bilaterally. Nasal mucosa: pink and moist. Septum: midline. Nasopharynx: normal to inspection. Dentition: good repair. Oral mucosa: moist with no thrush / no mucositis. Examination tongue: Appears normal. Posterior pharynx: normal. Tonsils: appear normally colored and ovoid. Neck: palpation reveals no cervical nodules. Thyroid: normal to palpation. Resp: lungs: clear anteriorly, posteriorly, laterally.

Impression: Impacted cerumen and headaches

Plan: Cerumen: deeply impacted and required use of curettes and suction bilaterally for removal.

Correct code:

69210-50 Removal impacted cerumen requiring instrumentation, unilateral

Preparing Your Organization


Medical Coders• Require Extensive Training for both

CPT and ICD code sets

• Training estimate 8-10 Hours

• Targeted Audits to monitor accuracy

• Remedial training likely required

Physicians• Overview training for ICD focused on

updated documentation requirements

• Training estimated 2 Hours

• Conduct Clinical Documentation Audits to monitor accuracy

• Remedial training by medical specialty advised as needed

Anita Kangat

+971501234086

[email protected]


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