Continuing with Chapter 8, we will do
Part 3. Physical Medicine and
Rehabilitation. A Physiatrist is a specialist
in Physical Medicine & Rehab. I worked
ten years in a rehabilitation hospital
and the physicians who worked primarily
with our patients were the physiatrists.
Don't confuse that term with the term
"psychiatrist" because they look and sound
very similar. Physiatrists primarily
work with therapy- physical, occupational
and speech- to accomplish whatever
treatment goals patient has. A physiatrist
uses E&M codes for the
professional service billing when
they're seeing the patient. There are
codes in this section of the Medicine
chapter that cover physical therapy
services, testing and measurement codes
to document the use of prosthetics and
physical performance testing. Physical
Medicine and Rehab also includes active
wound care management. We had many
patients that were there for wound care
when I was at the Rehab Hospital, so this
subsection also includes wound care.
Actual debridement is a surgical
procedure that's covered in the Surgery
chapter so you have to be sure when
you're reading these code descriptions
that you are differentiating between
debridement. Debridement is the term used
in these code descriptions so it's a little
bit confusing but it's the extent to
which you're doing it (that is the difference). Also, the codes in
this section talk about "selective" and
"non-selective". As far as your procedure,
are you selecting very specific tissue
that you're targeting for removal or are
you just cleaning up an area so you're
not zeroing in on specific pieces of
tissue but just really cleaning up an
area and that would be considered non
selective. (Ex.8.9 #2) Thirty minutes of water aerobic
exercises with a therapist for the
treatment of arthritis. Your CPT code
would be 97113 times 2. That is
because when you look up this code 97113,
it's described as "each 15 minutes".
So if your patient was seen for 30
minutes you've got to have that code
twice to account for the 30 minutes. You
notice also when you're looking up
"therapy", your main term is going to be
"physical medicine / therapy/ occupational
therapy". Then your "aquatic" in this
scenario, your aquatic therapy would be
in the next sub term "with exercises".
(Ex. 8.9 #4) Physician orders a re-evaluation of a
knee injury following a course of
athletic training. This is not, I don't
think written very well. What they're
actually asking you to do is code
re-evaluation of a plan of care because
when someone's been given athletic
training as a treatment, that (order) is coming
under the plan of care so the physician
is making sure that plan of care or the
course of treatment that he has told the
physical therapist or the athletic
trainer to do is working. So this is
a reevaluation of a physician's plan of
care to make sure the correct plan of
care has been given for the athletic
training following the knee injury. So
hopefully that clarifies that. It's just
not written very well. There is your
answer 97172. You see that your main
term is again "physical medicine /
therapy/occupational therapy"
athletic training would be your next
sub term and then re-evaluation. It is
important that you notice that
"re-evaluation" term because there are also
"evaluation" terms. So be sure you're
selecting the right one. Here's an
example not in the textbook that is
about the active wound care management.
Remember that you will see a question
like this, this one or similar to it, on
the exam. Provider note>The patient was
seen in the Wound Clinic. Debridement of
an open wound, 40 square centimeters , was
accomplished with a high-pressure water
jet with suction. Healing noted with
significant filling around the edges of
the wound. Instructions were given to
the patient for dressing changes and he
will be seen in the clinic next week
for further assessment. Then I've
just told you in my note there that this
is a "selective" process, very specific
tissue is being removed with this
high-pressure water jet with suction. The
index pathway is the "wound" as your main
term. Your main term is wound, subterms
"care. debridement and selective" to be sure
you're capturing the correct code.When
we read these codes 97597 is
debridement using the high-pressure
water jet with or without suction but
it's for the first 20 square centimeters.
This patient has a "40 square centimeter"
wound so we would have to add
another code 97598 for each additional 20
square centimeters or part thereof. So
that's how we would code this. If this
patient had had a 30 square centimeter
wound, we would also need both codes
because 97598 says each additional 20
square centimeters "or part thereof". It's
important that that is there. Not all the
codes give us that "or part thereof" (as part of the code description). I
like it when it tells us very
specifically that we can use that code.
Here's another example not in the textbook
about orthotic management and
prosthetic management. Prosthetic training,
lower extremity, 60 minutes. What is the
correct code? We would go back to our
familiar "physical medicine / therapy/
occupational therapy" as our main term.
Prosthetic training is our subterm. 97761
When we look up that code
description, it tells us it is "each 15
minutes" so we know we have to use that
code four times to account for 60
minutes> If you don't know, orthotics are
things that we put in our shoes, for
example, that help align our body
correctly. A prosthetic is when you are
replacing an entire joint like an arm
prosthesis or a leg prosthesis. A
prosthesis on the leg can be either
below the knee or above the knee but we
do a lot of prosthetic management in
Rehabilitation Hospitals primarily
because people are coming there for
rehab following an amputation of the
limb.
Totally different section-Qualifying
Circumstances for Anesthesia. There are
four CPT codes that can be used to
report qualifying circumstances or
additional information that is used for
patients that are undergoing anesthesia
that have a greater risk of complication.
The things that they talk about are
extreme age and that could be the very
old or the very young, total body
hypothermia, controlled hypertension or
possible emergencies. We're going to be
reporting qualifying circumstances
for anesthesia along with the code for the
anesthesia service. Here is an example
within this section, not in the textbook.
You will see this on an exam or one very
close to it. This is a physician note. The
patient arrived at the ambulatory care
center in respiratory distress with a
severe anemic condition. He is 90 years
old, however, he is an avid walker and in
pretty good shape. From our examination
and the results of tests, he appears to
have a GI bleed and he wishes to have it
repaired. The high probability of
complications was discussed at length
with the patient and his son. The patient
is of sound mind and desires to proceed
with the surgery. What CPT code would be
used to describe the qualifying
circumstances for anesthesia for this
patient, this 90 year old patient and the
answer would be 99100. What I think is
interesting here is in your index
pathway I had to look for this code
because it doesn't fall. I get why they
did it the way they did because you've
got three or four different things that
could come in this section. But you just
have to remember the anesthesia is your
main term and special circumstances
would be your sub term. Then you would
choose the extreme age. I guess it helps
if you remember that this section is
called "qualifying circumstances" and your
sub term in the index also includes
the word "circumstances". Maybe that would
help.
Moderate or conscious sedation, There are
two slides here that talk about this. If you have
had a colonoscopy, you may have had this
type of sedation where you are kind of
out of it, but you can respond to the
physician telling you to do different
things. The difference is when a patient
has this type of sedation, you are not on
the ventilator. Your airway is
still clear. You're able to breathe on
your own spontaneously but it does
require the presence of an independent
trained observer to assist the physician
in monitoring the level of consciousness
and the patient's physiological status.
Codes represent performance and
documentation of pre-sedation and post-
sedation evaluations, the administration
of the sedation and the monitoring of
cardio respiratory functions So even
though you're not on a ventilator, your
respiration status is being carefully
monitored. If the physician who performs
the sedation also performs a procedure
supported by the sedation, the physician
will supervise and direct an independent
trained observer who will assist in
taking care of the patient. So if your
physician is doing both the sedation and
the procedures there has to be another
person there to observe what's going on
with the patient. There are also codes
for when you have one physician doing the
procedure and one physician doing the
sedation. It's two different physicians.
Those are different codes. Codes are
also differentiated by time, how long
this takes.
Here's an example of a moderate sedation
question not in the textbook. You will see it
on the exam or something very similar to
it. A seven year old patient is seen for
a minor routine therapeutic service that
requires administration of moderate
sedation for 30 minutes performed by a
physician other than the physician
performing the therapeutic service. So in
this case, there are two physicians. We
don't need that trained observer because
we've got two physicians. You
would look under "sedation" as your main
term, moderate and then there's your
range of codes. When we read through
them, 99156 is for moderate sedation
services provided by a physician other
than the physician performing a service,
initial 15 minutes. Then there is an
age factor. This particular code is for
age five years and older. So there's your
initial 15 minutes. We know that this
person had moderate sedation for 30
minutes so we go back to our codes and
code 99157 is for each additional 15
minutes. You would have to include
both of those codes as your answer for
this moderate sedation.
Then there's a very broad section called
Other Services and Procedures that
really covers so many different things
but it is something you just need to be
aware of what's in there. For example,
hyperbaric oxygen therapy, I have worked
in hospitals where that was used for
someone who was in a diving accident and
they've got now I believe it's
nitrogen bubbles in their blood. So they
have to go into this hyperbaric chamber
that takes them back to the
depth that they were in in the water and
slowly brings them back to the pressure
that we have in our atmosphere. Then
those bubbles dissolve so it's a very
specific therapy. Ipecac is a
drug that's given, mostly in the
emergency department for a baby that's
eaten something he shouldn't have eaten, or a small child (not just a baby).
They will give them the Ipecac and watch them
until they vomited and vomited
to be sure that they've gotten
all of that toxic substance out of their system.
Sometimes it's medications,
sometimes it's poison mushrooms or other
plants that are poisonous to the child.
Another thing that's used is anogenital
examination and this is when you've got
a child you suspect has been sexually
abused and this examination is done for
court proceedings. It is magnified,
meaning any minute tears in the body
surface, either around the anus or the
vagina. They're going to be looking for
small tears that would indicate some
kind of trauma. It is a very specific code.
Phlebotomy is when you're just drawing
blood for a test. That also falls in this
section. Home Health Procedures and
Services- these codes are used by
non-physician healthcare professionals
to report services provided at a patient's
residence and this would include the
patient's home. It also includes assisted
living, group homes, non-traditional
private homes, custodial care or school.
So you really got just about all
settings there.
A physician is not using these home
health procedure codes. The physician is
using home visit codes are in the E/M
chapter and utilizing CPT codes other
than this group of codes for any
procedure that they are providing to a
patient living in a residence. So again,
depending on who you're coding for, you
would select different codes. Here's an
example. Home visit by a non-physician
health care professional to provide
mechanical ventilation care to a patient.
This is an example of a question not in
the textbook but you may very well see
it on the exam or something similar to
it. Home services would be your main term
in the index, mechanical ventilation your
sub term. 99504. There are also home
infusion procedures. These two codes
99601 and 99602 are used for home visits
by a non-physician professional and a
code for all the necessary solutions
required to deliver a therapeutic
service in one visit. What is not
included in these two codes are
the drugs.
Medication therapy management services
are when you have face-to-face
medication therapy management services
by a pharmacist. This is based on a new
versus an established patient and the
amount of time that was spent. The
guidelines specify that MTMS (medication
therapy management services)
documentation has to include a review of
pertinent patient history, a medication
profile, recommendations for improving
health outcomes and treatment compliance.
All those things have to be included in
the pharmacist documentation. If you have
any questions about Chapter 8 Part 3,
please post them in the discussion
board and I will attempt to answer them.
I hope you have a good day.
you