November 2016

Ask the Experts
For the Record
Vol. 28 No. 11 P. 30

Question:
Recently, a new father shared news via Reddit about how the hospital where his son was born charged $39.35 for his wife having "skin to skin" with the newborn following a C-section. One of our Facebook readers, Blair, wondered how this would be coded.

Response:
"Skin-to-skin contact" is not a procedure that would be coded on an inpatient chart. We aren't even required to code simple venous catheters, and those are at least invasive procedures. If a facility wishes to charge for various specific nurse services that it feels are over and above the usual ones provided during a cesarean or vaginal delivery, the additional services are typically added to the claim using internally developed "charge codes" rather than ICD or CPT procedure codes. As a side note, this isn't a physician charge; it's a facility charge.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 26 years.

 

Question:
I have seen conflicting information regarding coding of a first-degree obstetric laceration. Some sources indicate to utilize 0WQN0ZZ repair female perineum open approach. I have also seen 0HQ9XZZ repair perineum skin external approach. The physician simply checked off first-degree laceration, standard repair with no further documentation.

Dawn Zimmerman, RN, CCS
Buffalo, New York

Response:
Based on the guidance found in the ICD-10-PCS guidelines, which is further clarified in the Coding Clinic, Fourth Quarter 2014, obstetric perineal laceration repairs are coded to the deepest layer of tissue repaired. For a first-degree laceration, it is coded to the outermost tissue, which would be the skin of the perineum. The correct code assignment is 0HQ9XZZ.

Section (0)                Medical and Surgical
Body System (H)       Skin and Breast
Operation (Q)            Repair
Body Part (9)            Skin, Perineum
Approach (X)            External
Device (Z)                No Device
Qualifier (Z)              No Qualifier

— Kimberly Cunningham, CPC, CIC, CCS, is education manager at AAPC.

 

Question:
What will be the effect of the new category I CPT code for laparoscopic radiofrequency ablation of uterine fibroids?

Anonymous

Response:
From the coder's point of view: It isn't a big deal for coders themselves except for the need to be aware that the code changes. For example, if a coder has the T-code memorized and adds it to the claim out of habit, the old code will no longer be valid and using it after January will result in payment reduction or perhaps claim denial.

If the coder is involved in the authorization and/or billing process, knowing the patient's insurance's reimbursement policy for the procedure might be important.

From the payment point of view: New Technology codes changing to "regular" category I codes is encouraging from a payment point of view. Some payers won't pay for the "new technology" service, or they will pay at a discounted rate; preauthorization is typically required if the insurance will cover the service. FDA approved the procedure in 2012, Blue Cross Blue Shield (BCBS) of the Midwest has already approved payment since October 2014, and in 2015 it was approved by by BCBS of Michigan, so this is hardly an experimental procedure. However, United Healthcare still considers it unproven and not medically necessary for treating uterine fibroids.

From the patient's point of view: It's a big deal. Acceptance of the technique and increased likelihood of being reimbursed by third-party payers should encourage more physicians to learn the newer technique. The big deal is if the procedure is successful, it can replace forcing women to have a total hysterectomy to eliminate the fibroid tumor. For many women of childbearing age, this is a godsend; even if the fibroids may eventually grow back, it could permit pregnancy and term delivery in the interim. For women of all ages, it simplifies the procedure and the risks and greatly reduces recovery time and pain and risk of complications.

If the patient has an insurance or payer that does not cover it, the woman may have some tough choices to make. Does she want to tolerate the symptoms and hope that her insurance will pay it at a tolerably later date, pay out of pocket for the procedure now, or opt for the total hysterectomy that is typically covered at 100% by insurance? ("Typically covered at 100%" doesn't mean most insurance pays 100% of the hospital bill, it means the surgery is a fully covered service. Any contracted copays/deductibles would still apply.)

From the Centers for Medicare & Medicaid Services: Neither assignment of a HCPCS code nor approval of a service for assignment to a New Technology APC assures coverage of the specific item or service in a given case. To receive payment, a new technology service must be considered reasonable and necessary, and each use of a new technology service is subject to medical review for determination of whether its use was reasonable and necessary. See www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/
downloads/newtechapc.pdf.

From one of United Healthcare's medical plans, October 2016: Laparoscopic ultrasound-guided radiofrequency ablation (eg, Acessa) is unproven and not medically necessary for treating uterine fibroids. Further studies are needed to determine the long-term efficacy of this procedure and to evaluate the efficacy and safety of this procedure relative to other treatment options for uterine fibroids. See www.unitedhealthcareonline.com/ccmcontent/ProviderII/
UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Policies and Protocols/Medical Policies/Medical Policies/Abnormal_Uterine_Bleeding.pdf.

Getting a CPT code for a new surgical technique is a pretty big deal. See www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-process-faq/code-becomes-cpt.page.

Then you have to get it paid. See www.cimit.org/news/regulatory/cms_coverage.pdf.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 26 years.

 

Question:
It seems to me that remote coding jobs have dried up. I'm a seasoned coder with over 12 years' experience who was laid off in June of this year and has been looking for full-time work.

Since you seem to have a finger on the pulse of the coding world, has remote coding gone the way of the paper medical chart?

Cathy M. Catherine, LPN, CCS

Response:
Many health care organizations ramped up their coding staff and education initiatives in preparation for ICD-10 last year. As a result, the impact of the ICD-10 transition was not as significant as many had feared. This is a testament to the hard work and dedication of the HIM professionals across the country. There has been an industrywide effort this year to right-size staffing levels post-ICD-10. This has resulted in a larger supply of coders in the marketplace. Remote coding as a profession is not going away as market dynamics, such as increased demand for health care services and a greater number of coders retiring annually than entering the workforce, demonstrate the ongoing need for highly qualified coders. Coders with multiple skill sets, both inpatient and outpatient, will find an easier time maintaining employment.

— Andrea Romero is senior vice president of HIM operations for himagine solutions.

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