Okay we'll continue with Chapter 8
Part 2, the Medicine Chapter.
Cardiovascular Services- this section of
the chapter covers both diagnostic and
therapeutic services. I have listed
here my definition of what those
services would include. Your cardiac caths
would be considered "diagnostic"; CPR or
cardioversion would be considered
"therapeutic". Cardioversion is when your
heart is being too fast and different
drugs can be given or you can be shocked
in order to slow your heart down. So that
is what cardioversion is.
The cardiovascular section requires
really advanced knowledge of the cardiac
system, the different treatment options
that are available, and the guidelines
are very extensive around this chapter.
I'm just going to go over it briefly
because honestly, you would not, as a
beginning coder, be placed in a situation
where you would be coding cardiovascular
services. I certainly wouldn't feel
comfortable being the expert in this
case because I've only coded very basic
things in this chapter. But let's look at
some of those codes. The patient has
stenosis in the right coronary artery.
An AngioJet thrombectomy is performed
percutaneously to remove the
thrombotic lesion which is a clot.
Then, as a reminder to assign the HCPCS
modifier, I have a little star there
reminding you that this is referring you
to the modifiers found on the inside front
cover of your CPT code book. There are
modifiers approved for hospital
outpatient use and it's called Level II
HCPCS /national. Those modifiers
identify specific blood vessels in the
body so the scenario is reminding you to
assign that modifier to identify that
specific blood vessel in the body.
When we look up main term "thrombectomy"
and we use our descriptors of
"percutaneous" and "coronary artery" we get
92973 and the
modifier -RC identifies the right
coronary artery.
That was pretty straightforward.
Cardiac stress test via treadmill performed
under physician supervision with
interpretation and report. "Stress tests"
would be your main term in the index with
cardiovascular as your sub term. When
you read the code descriptions there in
that range, 93015 would be the stress
test which includes supervision,
interpretation and report. You notice
in your scenario, you're given all three
of those descriptors. Here is a
cardiovascular service for PTCA which
is a percutaneous transluminal coronary
angioplasty. This is a PTCA of the left
anterior descending artery with
placement of a drug-eluting stent. The
stent is going to keep this vessel open
and the drugs are going to help to keep
it open., It's a reminder again to
assign a HCPCS modifier to identify
the left anterior descending artery.
"Stent" is the main term in the index and
placement, transcatheter, intracoronary (are the subterms).
Transcatheter means you have a catheter
that's been threaded through the vessel
and then the doctor puts the stent into
the body through the catheter. That's
what "transcatheter" means- "through the
catheter into the coronary vessel". "Intra
coronary", your medical terminology really
comes into play when you're reading
procedures or operative reports.
Stay on top of that cardiac anatomy and
physiology, well, really all the body
systems. Left heart catheterization with
an intraprocedural injection for left
ventriculography.
Cardiac catheterization would be your main
term, "left heart", then "with
ventriculography" (as subterms) and when we look up
these code descriptors, here the one that
fits what we're doing. 93452 which
does say it is a left heart catheterization
and it uses the word intraprocedural
injection for left ventriculography. It
does tell us imaging supervision and
interpretation (is included) when performed. That means
it is "when performed"; it is not mandatory. So
the scenario we've been given does not
tell us imaging supervision
interpretation (were performed) but we can still use this
code because it's not mandated that that
be part of that code description. Let's
go to a new section. This is the
Pulmonary Service. Codes are used for
pulmonary testing and when an E/M service
is performed separately. We are going to
be looking again at codes from E/M being
assigned along with your pulmonary
testing code. Codes 94010 through
94799, which is a lot codes, includes the
performance of lab procedures and the
interpretation of those results.
Spirometry for bronchodilator response
evaluation. In other words, (in this scenario) the
patient's been given a drug or
medication to dilate bronchioles and now
they're going to do a spirometry to see
how the patient is responding to the use
of that bronchodilator. Spirometry is your
main term. It gives you quite a few codes
there. It also says "See Pulmonary,
Diagnostic, Spirometry, Evaluation and
I think that's the course I would go.
When we go to 94060 ,it does say
bronchodilator responsiveness spirometry.
Your words do not have to be in the
exact same order as the words in your
coding scenario but they should be
similar enough that you can identify
that you've chosen the correct code. The
next section-Allergy and Clinical
Immunology. This includes allergy shots,
which are very common. Allergy shots are
defined by CPT
as "Allergen immunotherapy" and it does
remind us in this case, a separate
office visit code should not be
reported unless some other identifiable
service was provided during the visit,
something totally unrelated to this
allergy shot. More complete definitions
for all aspects of this particular
section Allergy and Clinical Immunology
are in the CPT code book and in the
guidelines preceding this section. This
exercise is an allergy shot for grass
pollen. It includes the extract and when
we look that up, "allergen immunotherapy"
are the terms we look up for our main
term in the Index then allergen extract,
injection and provision (are the subterms).
New section, Hydration, Therapeutic,
Prophylactic, and Diagnostic Injections
and Infusions, and Chemotherapy and Other
Highly Complex Drugs or Highly Complex
Biologic Agent Administration.That's
a mouthful, isn't it? But it falls all
under one heading in this section. The
guidelines in this sections are
extremely important. They are always
important but to me they're extremely
important here because it's so easy to
make a mistake. Notice that there are
reporting requirements that are
different for physicians and facilities.
You have to be sure you know who you're
coding for and use the guidelines that
instructs you for that setting or that
person that you are coding for. For the
physician, the initial service code under
this section is chosen based on the
reason for the encounter. This is totally
different for the facility reporting.
When a facility is looking at initial
service, it is going to be based on the
hierarchy so if the patient got all
these things, a chemotherapy infusion is
going to be the thing that you are going to code as
your initial service. The other
things would fall below that one. In the
same section, if it is elected to
administer multiple infusions or injections
or combination of infusions and
injections during the same encounter,
you're only going to use one initial
service code unless your medical
protocol requires that two separate IV
sites be used. There are times that
the nurses will start two different
IVs because of two different drugs
that say not to administer to the same
portal. This is one of those sections too
where payer guidelines are extremely
important. If you're going to work in the
outpatient setting, you're encouraged to
be familiar with your Medicare claims
processing manual. That really helps you
understand what Medicare is going to
cover. Really, I should have said
"outpatient". It can be outpatient and
inpatient. You really have to understand
how that's going to be coded . If you
don't follow the Medicare rules around
this, when the claim is submitted
and runs through the scrubber, that's when
they're going to have all these edits
hitting telling you you can't code it
this way, you can't code it this way and
it's going to tell you why you can't.
It would be very likely a Medicare edit
where Medicare's rules and regs say no,
you can't code it this way. So just a
reminder, that no matter where you're
coding, you're going to have to really
become very familiar with your payer
guidelines because that dictates how
those claims can be submitted. Let's look
specifically at hydration within this
subsection. Two codes- 96360 and 96361
are used for an IV infusion of
prepackaged fluids and electrolytes. In
other words, if you see those bags
hanging of normal saline when someone comes
out of surgery or come into the ED very
dehydrated, they would hang these
these prepackaged fluids to get the
person hydrated again. Code 96360
is up to an hour, 31
minutes to one hour and 96361
is each additional hour. If you
had, you were hanging something that ran less
than 31 minutes, like 30 minutes and
below, you would not code it as "hydration".
It was fall under E/M or an ED
visit code. These codes are not used when
the purpose of IV fluid is to keep the
line open. In other words, say you just
wanted to run to keep that line going in
case you need to pop in and put in
another infusion. You can't use the codes
for that reason. For facility reporting,
the hydration infusions are at the
bottom of the hierarchy when you're
reporting chemo, non-chemo and hydration.
I had the facility hierarchy where the
chemo infusion is first, the hydration
was at the bottom and that is how you
would order your codes. Here's an example of a
hydration. Patient seen in the ED for severe
dehydration and IV infusion of fluids
is ordered for hydration. The infusion was
concluded in two hours. We look up
"intravenous infusion" as our main
terminal in the Index. Hydration would be our
subterm- gives us two codes. When we look at
these two codes, 96360 is the initial 31
minutes up to an hour and code 96361
is for each additional hour. So in this
particular example, we would have two codes.
Now let's look at chemotherapy. Various codes
differentiate between the mode of
administration of the chemo, whether it's
infusion or push, the length of time and
the specific body sites. It's very
important to read all the descriptions
carefully. If you're coding Medicare
claims, you're also going to pick up a J
code that's in the Level II HCPCS
and this would either be, we used to have
HCPCS books that we had students buy.
This is when I was a student, so long
time ago but we weren't using them
enough to justify the cost and for the
most part, coders are using software to
find these codes so we do not require
the students buy the Level 2 HCPCS
manual. But just so that you know, any
time you are coding a product, whether
it's a substance or some different
equipment, you would be picking up codes
from this HCPCS manual and the codes
that identify drugs are the J-series. Code
describing the placement of pumps,
catheters and reservoirs are found in
the Surgery section (of CPT) so you will be
pulling codes from other parts of the
code book. When additional services are
provided on the same day as the chemo and
are independent of the chemo, the
physician may bill the additional
services separately, like an E/M
visit we talked about earlier. Here's our
first problem. IV infusion of Cisplatin
and Cisplatin is identified as a
chemotherapy drug administered for two
hours. There's your pathway and the
codes that you would select for this
scenario.
An intra-arterial chemotherapy
administration, IV push. So our
mode of administration is a little bit
different on this one but when we look
up the chemotherapy as our main term,
"intra-arterial push" is a very specific
sub term leading us to 96420. Here's an
example, not in our textbook,but one we
will see on the exam, either this one or one very
close to it. I say that because what I will
do sometimes is use the same scenario
but change the times or change some
small thing within a scenario that
tells me you're reading, when you know
that this is the type of question you
saw on the podcast but you know that you
have to look at the code book and read
the code descriptions to choose the
right code that has the right time
component. This patient is undergoing
chemo, seen in the clinic for a refill for
her portable infusion pump. Chemotherapy,
pump services, portable would be the path
that we would use to find 96521. Notice
that there is no description for the
refill. We're just going to look under
pump services, a broader term than refill
but it is for a portable pump, which is
the case here.
injections and infusions -these are
looking at drugs that are not
chemotherapy. The codes are
differentiated according to the route of
administration. You will see IV, IM and
the injection status- is it an initial,
sequential or concurrent? The specific
substance injected must be reported with
the different code, another code. For
Medicare cases, as I mentioned earlier,
you would use a J code from the HCPCS
manual and for non-Medicare cases,
probably code 99070 to be reported. The
coder really has to know individual
payers, Medicare and all the other
payers that you're facing in your
institution. This series of codes is
not for allergy injections or allergy
shots. They have their own codes as we
mentioned in an earlier slide. Here's an
example. What is the correct CPT code
assignment for an IM injection of
Leukine? Leukine is used to prevent
infection in cancer patients but it is
not a chemotherapy drug. If I had not
given you this information, you would
need to go to Google search engine, find
out what kind of drug Leukine was so you
would know how to code it. Then we have
another J code that would be assigned
to identify the Leukine.
I have heard it pronounce both ways. Here
would be the pathway. Injection,
intramuscular ( which is the route),
therapeutic. It is considered therapeutic
because it's being given to treat the
patient who has cancer. Two codes are
given there and 96372 fits our code
description.
If you have any questions about Chapter
8 Part 2 podcast, or any of
these questions or exercises within
these sections, please post them in
discussion board and I will try to
answer them. Please include the path that
you used to try to find your code. Thanks
so much and have a good day.