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Clinical Documentation Excellence:CPT® Coding Updates for 2015

Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador

Kelly Spell, CCS, CPC, CPC-H, CAHIMS,AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador

April Rushing, RHIA, CCS-P

Today’s SpeakersMissy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador serves as the University of Mississippi Medical Center’s (UMMC’s) leader for hospital coding and facility charge capture for emergency services.

Kelly Spell, CCS, CPC, CPHIMS, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador specializes in Health Information Management build for the Epic electronic health record team at UMMC.

April Rushing, RHIA, CCS-P is a senior leader for the hospital outpatient coding department at UMMC.

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DisclaimerSpeakers and planning committee members have no significant financial interest and this presentation does not have any commercial support. There is no investigational or unlabeled uses of a product in this presentation.

The material is designed and provided to communicate information about clinical documentation, coding and compliance in an educational format and manner. The authors are not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational content provided is accurate and useful. Applying best practice solutions, altering work flow, and achieving results will vary with each individual and clinical situation.

1. Identify new 2015 CPT®codes and descriptions

2. Identify revised 2015 CPT®codes and descriptions

3. Examine the LCDs for the new and revised 2015 codes

Learning Objectives

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Current Procedural Terminology (CPT®)codes were developed by the American Medical Association and first published in 1966. The purpose of CPT® is to provide a uniform language accurately describing medical, surgical and diagnostic services. It serves as an effective means for reliable nationwide communication within the health care industry.

What is CPT®?

• Physicians for their services, not dependent upon location

• Hospitals for Outpatient Services• Third party payers for reimbursement

of Outpatient Services

Who uses CPT®?

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• Anesthesia• Surgery• Radiology• Pathology• Laboratory• Medicine• Evaluation and Management

What services are represented by CPT®?

Focusing today only on the codes within the surgical section.

What services are represented by CPT®?

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To Do List…

• Order 2015 CPT® codebooks• Review 2015 CPT® code changes• Review and update superbill and

chargemaster• Update software• Train staff on upcoming CPT® changes

Over 500 CPT® Changes

Revisions Include:

• With or without deleted, added ‘including when performed’• Includes changed to ‘including’• Single changed multiple (s) such as tumor changed to tumor(s)• Listing out every method deleted, changed to ‘any method’

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Symbols in CPT®

Revised code

New code

Musculoskeletal: Arthrocentesis

20600, 20605, 20610 have been revised to read without ultrasound guidance

NEW CODES20604 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

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Open Treatment for Rib Fractures21811 Open treatment of rib fracture(s) with internal fixation, includes

thoracoscopic visualization when performed, unilateral; 1-3 ribs

21812 ;4-6 ribs

21813 ;7 or more ribs

DELETED:

21800 Closed treatment of rib fracture, uncomplicated, each21810 Treatment of rib fracture requiring external fixation (flail chest)

Percutaneous Vertebroplasty22510 Percutaneous vertebroplasty (bone biopsy included when performed),

1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

22511 ;lumbosacral

+ 22512 ;each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

DELETED:

22520 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,unilateral or bilateral injection, thoracic

22521 lumbar22522 each additional thoracic or lumbar vertebral body

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Percutaneous Vertebral Augmentation22513 Percutaneous vertebral augmentation, including cavity creation

(fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

22514 ;lumbar

+ 22515 ;each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

DELETED:

22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation; thoracic

22524 lumbar22525 each additional thoracic or lumbar vertebral body

Total Disc Arthroplasty

22856 has been revised to become the parent code for 22858

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

+ 22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

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Arthrodesis of Sacroiliac Joint

27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

27280 revised to indicate an open procedure

27280 Arthrodesis, sacroiliac joint, open

Pacemaker or Implantable Defibrillator

33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

33271 Insertion of subcutaneous implantable defibrillator electrode

33272 Removal of subcutaneous implantable defibrillator electrode

33273 Repositioning of previously implanted subcutaneous implantable defibrillator electrode

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Cardiovascular

33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

+ 33419 additional prosthesis(es) during same session (List separately in addition to code for primary procedure)

DELETED:

33332 Insertion of graft, aorta or great vessels; with shunt bypass

Transcatheter Procedures

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

37216 without distal embolic protection

37218 Transcatheter placement of intravascular stent(s), intrathoraciccommon carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation

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Endovascular Revascularization

37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

+ 37237 each additional artery (List separately in addition to code for primary procedure)

Liver

47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation

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Urinary52441 Cystourethroscopy, with insertion of permanent adjustable

transprostatic implant; single implant

+ 52442 Custourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)

Esophagoscopy

43180 Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker’s deverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair when perfomed

43216 Esophagoscopy, flexible, transnasal; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

DELETED:

43350 Esophagostomy, fistulization of esophagus, external; abdominal approach

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Intestines: Endoscopy, Stomal44380 Ileoscopy, through stoma; diagnostic, with or without including

collection of specimen(s) by brushing or washing, when performed (separate procedure)

44381 ;with transendoscopic balloon dilation

44384 ;with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

44385 Endoscopic evaluation of small intestine pouch (abdominal eg, Kockpouch, ileal reservoir [ S or pelvic J]) pouch; diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure)

44386 with biopsy, single or multiple

Intestines: Endoscopy, Stomal44388 Colonoscopy through stoma; diagnostic, with or without including

collection of specimen(s) by brushing or washing, when performed (separate procedure)

44401 ;with ablation of tumor(s), polyp(s), or other lesion(s) includes pre- and post-dilation and guide wire passage, when performed)

44402 ;with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed)

44403 ;with endoscopic mucosal resection

44404 ;with directed submucosal injection(s), any substance

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Intestines: Endoscopy, Stomal44405 ;with transendoscopic balloon dilation

44406 ;with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures

44407 ;with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures

44408 ;with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube,

when performed

Endoscopy, Sigmoid45330 Sigmoidoscopy, flexible; diagnostic, with or without including collection

of specimen(s) by brushing or washing, when performed (separate procedure)

45337 ;with decompression (for pathologic distention) of volvulus(eg, volvulus, megacolon), including placement decompression tube, any method when performed

45340 ;with dilation by transendoscopic balloon, 1 or more strictures dilation

45346 ;with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

45347 ;with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

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Endoscopy; Sigmoid, continued45349 ;with endoscopic mucosal resection

45350 ;with band ligation(s) (eg, hemorrhoids)

Colonscopy

45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without including collection of specimen(s) by brushing or washing, with or without colon decompression when performed (separate procedure)

45388 ;with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

45386 ;with dilation by transendoscopic balloon, 1 or more strictures dilation

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Colonoscopy, continued45389 ;with endoscopic stent placement (includes pre- and post-

dilation and guide wire passage, when performed)

45390 ;with endoscopic mucosal resection

45393 ;with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube,

when performed

45398 ;with band ligation(s) (eg, hemorrhoids)

Take Away

Get a new CPT® book and become very familiar with the codes for your service.

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LOCAL COVERAGE DETERMINATIONS

What is an LCD?

What is an LCD?

Local coverage determinations (LCDS) are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states: “For purposes of this section, the term ‘local coverage determination' means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).”

For LCD searches visit:http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Mississippi&CptHcpcsCode=45380&bc=gAAAAAAAAAAAAA%3d%3d&=&

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CMS WEBSITE

LCD L30304Colonoscopy and Sigmoidoscopy-Diagnostic

Juridsiction:Mississippi

LCD L30304Colonoscopy and Sigmoidoscopy-Diagnostic

Definitions:1. Sigmoidoscopy (CPT 45330-45335, 45337-45342, 45345) is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon.2. Colonoscopy (CPT 44388-44397, 45355, 45378-45387, 45391, 45392) is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum.

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LCD L30304Colonoscopy and Sigmoidoscopy-Diagnostic• 013x Hospital Outpatient• 014x Hospital - Laboratory Services Provided

to Non-patients• 071x Clinic - Rural Health• 085x Critical Access Hospital

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INPATIENT ONLY ?

On list for 2014:

21810 – Treatment of rib fracture

New codes may be on list for 2015

*21811-21813 Open Treatment of rib fracture(s)

INPATIENT ONLY ?

On list for 2014:

27280 – Fusion of sacroiliac joint

Revised code on list for 2015

27280 Arthorodesis, sacroiliac joint, open

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INPATIENT ONLY ?

On list for 2014:

37215 – Stent carotid artery

Revised/new codes on list for 2015

37215-37218 Stent cervical carotid, intrathoraciccarotid or innominate

INPATIENT ONLY ?

33418 *No data on Transcatheter mitral valve repair, but strongly suspect it will be INPT only.

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Questions & Answers

ICD10@umc.edu

Join us in 2015 January 21st at noon

Clinical Documentation Excellence Program Overview

This session will define the importance of Clinical Documentation Excellence at UMMC. The Clinical Documentation Excellence team will provide an overview of the program and

academic department composition. Key objectives and initiatives addressed in collaboration with each academic department team at UMMC will be reviewed.

Learning Objectives:

1. Define Clinical Documentation Excellence program at UMMC.

2. Identify academic department team composition.

3. Review Initiatives and objectives of Clinical Documentation Excellence teams.