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Counting Problems Addressed for Medical Decision Making
If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?
Question:
If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?
Answer:
No, sorry, unfortunately it does not work that way. The problems are no additive or cumulative. One stable chronic illness and one acute uncomplicated illness without systemic symptoms is still Low Problems Addressed.
*This response is based on the best information available as of 03/24/22.
ER Visit Coding
What code do we charge for an ER visit when our physician was called to the ER by the ER doctor? The patient has Medicare.
Question:
What code do we charge for an ER visit when our physician was called to the ER by the ER doctor? The patient has Medicare.
Answer:
If the patient was not admitted by you to the hospital (e.g., they were admitted by another service or discharged), then you code it as an ED visit, 9928x, when the payor does not recognize the consultation (9924x) codes.
*This response is based on the best information available as of 03/24/22.
Capsulectomy with Breast Reconstruction Implant Exchange
We billed 19371 (capsulectomy) with a breast reconstruction implant exchange (19342 – larger to smaller). We were denied 19371. Should we have used modifier 59 on 19371 to get paid?
Question:
We billed 19371 (capsulectomy) with a breast reconstruction implant exchange (19342 – larger to smaller). We were denied 19371. Should we have used modifier 59 on 19371 to get paid?
Answer:
This Medicare National Correct Coding Initiative (NCCI) edit is a dilemma. CPT implies that you are allowed to use both codes – 19342 and 19371 (or even 19342 and 19370) – but Medicare won’t pay both codes. It would not be accurate to bypass the NCCI edit with modifier 59 when the procedures are performed on the same side. Modifier 59 may be used when the procedures are performed on different sides.
Acute versus Chronic Conditions for Office E/M Services
When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on if the condition is considered a chronic or acute condition?
Question:
When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on if the condition is considered a chronic or acute condition?
Answer:
The AMA defines chronic as: A problem with an expected duration of at least a year or until the death of the patient.
An Acute problem is “A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.” An acute problem can be uncomplicated, acute complicated or acute with systemic symptoms. Please reference thislinkfor the AMA definitions.
Keep in mind the practitioner should document the whether the condition is acute or chronic if the condition is stable or exacerbating.
Hartmann or Partial Colectomy
My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier?
Question:
My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier?
Answer:
The correct code for this procedure would be 44140. Code 44140 is the base code for 44143 with the only difference being a skin level colostomy, so it would be inappropriate to code 44143-52 as there is an established code already in place.
*This response is based on the best information available as of 03/24/22.
Catheterization Codes in Vascular Coding
Are there any vascular CPT codes that still allow separate reporting of selective and non-selective catheterization codes?
Question:
Are there any vascular CPT codes that still allow separate reporting of selective and non-selective catheterization codes?
Answer:
Yes, the following procedures still allow separate reporting of catheterization codes
- Non- lower extremely, stenting, angioplasty, for example subclavian or renal arteries
- Peripheral embolization, for example hypogastric artery embolization during EVAR or uterine fibroid embolization
- Thrombolysis and thrombectomy
- Diagnostic angiograms and venograms (with the exception of cervical/cerebral and renal angiograms)
- IVUS
- TEVAR
