September 2018

Ask The Experts: Questions? We Have Answers
For The Record
Vol. 30 No. 8 P. 6

Question:
I have a question regarding radiography and biomedical imaging that was initiated by a coding scenario. Historically, if a breast ultrasound (CPT 76642) was done on the same date but at a different time and then the patient returned later in the day for an ultrasound guided biopsy (CPT 19083 -XE), we would code with a modifier XE. Can we bill with the XE in this scenario?

A CPC at a New England hospital

Response:
Noted facts from the scenario include Breast ultrasound (CPT 76642), Ultrasound guided biopsy (CPT 19083-XE), procedures performed on same date, and procedures done at different time on same date.

CPT Code Definitions (CPT 2018 Professional Edition)
• CPT 76642: Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited. Report 76641, 76642 only once per breast, per session. Listed under Diagnostic Ultrasound Category. CPT page 468.

• CPT 19083: Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous, first lesion, including ultrasound guidance. CPT page 99.

Modifier Definitions (CPT 2018 Professional Edition)
• Modifier XE: Separate Encounter * (HCPCS modifier for selective identification of subsets of Distinct Procedural Services [59 modifier]). CPT page 757.

• Modifier 59: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. CPT page 755.

CMS Guidance
Pursuant to CMS Manual System, Pub 100-20 One-Time Notification, Transmittal 1422, Effective January 1, 2015 (available at www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R1422OTN.pdf), "CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows: XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter. … These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available."

Scenario Response
• A diagnostic breast ultrasound (CPT 76642) and an ultrasound guided biopsy (CPT 19083) were performed on the same date of service but at different sessions for a patient.

• The provider billed CPT 76642 and CPT 19083, which was modified with "XE."

• Modifier "XE" was used to indicate separate (distinct) procedure for CPT 19083 because the procedures were performed at different times (sessions).

• Historically, modifier 59 is used to indicate a distinct procedural service.

• Effective January 1, 2015, CMS regulations brought forth four new modifiers to give more specification to modifier 59 (distinct procedural service). One of those new modifiers XE is defined as "a service that is distinct because it occurred during a separate encounter."

• Indicators used for conclusion:

- The description of the procedures performed.

- Two separate procedures were performed at different sessions on the same date. (Breast ultrasound was performed but not at the same time as the breast biopsy, which used ultrasound guidance.)

- A modifier is necessary to indicate the procedures were performed on the same date but separately.

- Modifier 59 indicates a separate procedure.

- CMS regulations indicate modifier XE gives a more specific description of modifier 59.

Conclusion
Based upon the above indicators, it appears it is appropriate to bill the following:
• CPT 76642: Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed (limited);

• with CPT 19083: Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous, first lesion, including ultrasound guidance; and

• modified with XE: Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.

— Rolando Russell, MBA, RHIA, CPC, is program director, MBC, at Ultimate Medical Academy.

Follow-Up Question:
I wanted to ask for additional clarification as I re-review the 2018 CMS National Correct Coding Initiative (NCCI) guidelines.

The 2018 NCCI policy manual states the following:

"9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (Ultrasonic guidance for needle placement ...) when performed in different anatomic regions on the same date of service. Physicians should not avoid edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service."

If the decision point isn't separate encounters or separate times of the day but rather services must be of "different anatomic regions" on the same date of service, then would we not be able to bill in our scenario? The content above in italics represents changes in the guidelines for 2018. I believe in 2017 it didn't matter if it was a separate region; you couldn't bill a diagnostics ultrasound of any region with an ultrasound-guided procedure on the same date of service. Would it matter in our scenario that CPT 76642 was performed later than 19083 was performed with regards to the guidelines above?

A CPC at a New England hospital

Response:
I still think you can bill as you have.

This is what I see: You're focusing on this part of the NCCI policy: "evaluation of an anatomic region and guidance for a needle placement procedure."

The NCCI references CPT code 76942: Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

It makes sense that you can't bill for guidance when doing an ultrasound because that's part of the procedure.

This code is for guidance only. That's not what you're billing for.

Your code, 76642, is for the actual breast ultrasound, which it appears is performed on the patient first. Then it seems they perform a breast biopsy, CPT 19083, probably because of something seen on the ultrasound. CPT 19083 includes ultrasound guidance done at the time of biopsy.

Therefore, I don't think you have to worry because you're not actually trying to bill the "ultrasound guidance" alone.

— Rolando Russell, MBA, RHIA, CPC

 

Question:
I am an ancillary coder at an acute care facility. We are having issues with whether we should be using the RAD (radiology report) results to code, as well as the script provided by the MD. Also, could you provide an example for us?

In one of our examples, MRI for knee pain, we are told to code RAD result of fracture.

Beverly Popovich, RHIT, remote coder

Response:
According to the ICD-10-CM Official Guidelines for Coding and Reporting, section IV, K, for outpatient coding of radiology exams, the most specific diagnosis known at the time of coding should be reported.

If the MRI was ordered for knee pain, but has been interpreted with a definitive diagnosis of fracture at the time of billing, then the appropriate code for the fracture should be reported.

If the exam has not been interpreted at the time of billing, the diagnosis code for knee pain would be reported.

Definitive diagnoses related to the reason for the exam would be reported when known. Incidental findings may be reported as secondary diagnoses.

The guidelines may be found at www.cdc.gov/nchs/icd/icd10cm.htm.

— Donna Richmond, BA, RCC, CIRCC, CPC, is senior healthcare consultant at Panacea.

 

Question:
I recently got audited and "dinged" on an ancillary account. The patient had a complete blood count, CMP, and PROTIME test, and the diagnoses listed were D64.9 and Z79.01. I coded D64.9 as admitting and primary then Z51.81 and Z79.01. I was told that I should have listed Z51.81 as my admitting and primary code. I cannot find any documentation stating this rule. Is there such a rule or was this just the auditor's decision?

A coder in Pennsylvania

Response:
What was the reason the patient came to see the doctor, a specific medical problem? Or was it only a scheduled visit to monitor for labs? And what did the provider document?

If this was documented as a scheduled set of labs tests because the patient was on an anticoagulant that needed to be checked regularly, and "by the way" the patient had anemia, then I'd think the auditor was probably correct. But if the patient came to the doctor with anemia, and was on an anticoagulant so the doc was worried about the anticoagulant perhaps being supratherapeutic, then I'd say the anemia would be both the chief complaint and the primary diagnosis.

Were you dinged and told to sequence it differently just to get paid, or because the coding was incorrect? So we're back to "it depends on what the chart says."

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris Health System in Houston and a contributing editor at For The Record.

Follow-Up Question:
These are usually nursing home patients, so we have no idea why the test was ordered. We do not get provider documentation as to why the doctors order blood work, we just get a script with the test and the diagnosis. This is coding for the Ancillary Outpatient Testing. Also, the anemia was listed as first diagnosis on the script.

The chart would get paid either way.

A coder in Pennsylvania

Response:
If that's the only information I had, I would code them in the order listed by the MD.

And I'd expect the consultant to defend his/her resequencing with regulatory support.

— Judy Sturgeon, CCS, CCDS

 

Question:
I do coding for Outpatient Labor and Delivery, where pregnant patients are seen for abdominal cramping, contractions, and other related pregnancy problems. Patients who have an RhD-negative blood type need to get a RhoGAM injection at 28 weeks. These patients are registered here for the RhoGAM injection. How would I code this?

Z29.13, Encounter for prophylactic Rho(D) immune globulin

AHA 17:4Q: p17 Prophylactic injection of anti-D antibodies during prenatal visit.

Question: A 28-week, RhD-negative pregnant patient with a history of previously delivering an RhD-positive baby receives a prophylactic injection of anti-D immune globulin during her prenatal visit. The patient does not have isoimmunization. What is the appropriate ICD-10-CM diagnosis code assignment for this visit?

Answer: Assign code Z34.83, Encounter for supervision of other normal pregnancy, third trimester, to indicate this is a normal pregnancy. Assign also codes Z31.82, Encounter for Rh incompatibility status, and Z3A.28, 28 weeks of gestation of pregnancy. Since the anti-D immune globulin was given as a prophylactic measure and the patient does not have isoimmunization, a code from subcategory O36.01, Maternal care for anti-D [Rh] antibodies is not appropriate.

The use of anti-D immune globulin does not mean the pregnancy is not normal. RhD factor is a protein that can be present on the surface of red blood cells and is passed from the parents to their children. Some individuals are RhD positive; while others do not have the RhD factor and are RhD negative.

Virginia Dunlap, CCA, remote coder for Excela Health

Response:
Please see the following two Coding Clinic issues. I found an additional Coding Clinic regarding if the mother delivers and requires the RhoGAM injection. See the second Coding Clinic.

Per Coding Clinic, fourth quarter 2014, page 17, we are to assign the following codes when a 28-week, RhD-negative pregnant patient with a history of previously delivering an RhD-positive baby, receives a prophylactic injection of anti-D immune globulin during her prenatal visit: Assign Z34.83, Encounter for supervision of other normal pregnancy, third trimester, to indicate this is a normal pregnancy. Assign also codes Z31.82, Encounter for Rh incompatibility status, and Z3A.28, 28 weeks of gestation of pregnancy.

Per Coding Clinic, third quarter 2015, page 40, we are to assign the following codes when an RhD-negative mother delivers at term without complications, and is administered RhoGAM prophylactically during the admission: Assign code O26.893, Other specified pregnancy related conditions, third trimester, along with other codes to represent the delivery. Code Z67.91, Unspecified blood type, Rh negative, may be assigned as an additional diagnosis, if the blood type is not known. If the blood type is known, a more specific code from category Z67 can be assigned.

Codes in category O36.0, Maternal care for rhesus isoimmunization, are not appropriate since the patient does not have isoimmunization. Prophylaxis is being given to prevent isoimmunization. Additionally, code Z31.82, Encounter for Rh incompatibility status, is not appropriate, as according to the ICD-10-CM Official Guidelines for Coding and Reporting, this code may only be reported as the principal or first-listed diagnosis.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris Health System in Houston and a contributing editor at For The Record.

Follow-Up Question:
Thanks for the answer. But this still is not answering my question. This fourth quarter 2014, page 17, Coding Clinic is exactly how I have been coding the RhoGAM injections given at 28 week (which is routine for negative blood types). There is a new code that came out last year: Z29.13, Encounter for prophylactic Rho(D) immune globulin.

After I saw this code, I thought this would be more appropriate to use. So I was coding Z34.83, Z29.13, and Z3A.28. What I want to know is should I be coding these accounts this way or Z34.83, Z31.82 or Z29.13, and Z34.28.

I also had read the third quarter 2015, page 40, Coding Clinic. I thought this to be a different scenario, since this is an RhD-negative mother who has already delivered. Her baby must have an RhD-positive blood type for her to need a prophylactic RhoGAM injection after delivery. In this scenario, O26.893 is assigned along with other codes to represent the delivery. The accounts that I code are prenatal patients who either need a RhoGAM injection at 28 weeks because they have an RhD-negative blood type or some of the patients with negative blood, present with bleeding in early pregnancy, and receive a RhoGAM injection at this visit, for which I was coding Z29.13, O20.9, and Z3A.XX.

So, to sum this all up, should I be using the O26.893 or Z31.82 or Z29.13 for prenatal patients with an RhD-negative blood type receiving a RhoGAM injection at 28 weeks (routinely)?

And also, which code would be appropriate for a prenatal patient with an RhD-negative blood type who presents with early bleeding or a miscarriage and receives a RhoGAM injection?

Sorry for the confusion; I just want to be coding these accounts correctly. I have been researching RhoGAM injections, and there is not much coding information out there.

Virginia Dunlap, CCA

Response:
Here's what I'd do. Look at the text of the two codes in question.

In the first, Z29.13, you're actually providing the injection. Z29 category is "other prophylactic measures."

In the second, Z31.82, you're providing procreative management for or due to her RhD-negative status. The Z31 category is "procreative management."

So, if you're only reviewing past medical history and/or doing blood typing, and managing her RhD-negative status, but you don't give her the injection, I'd only use Z31.82. If you're actually providing the injection, then I'd code both of them.

You should not be using the O26.893 for prenatal patients with an RhD-negative blood type receiving a RhoGAM injection at 28 weeks (routinely), as per the 2014 Coding Clinic below ("Since the anti-D immune globulin was given as a prophylactic measure and the patient does not have isoimmunization, a code from subcategory O36.01, Maternal care for anti-D [Rh] antibodies, is not appropriate.") I'd code both the Z31.82 and the Z29.13 as per my explanation below. One is to identify procreative management of the pregnant mother, and the other is to identify specifically what treatment was needed. You might only need to code the procreative management, but I feel that also reporting the detail on the injection provided is consistent with coding rules.

For a prenatal patient with an RhD-negative blood type who presents with early bleeding or a miscarriage, and receives a RhoGAM injection, the acute reason for presentation would be the first-listed diagnosis (diagnoses) and then I'd code both the Z31.82 and the Z29.13.

— Judy Sturgeon, CCS, CCDS

 

Question:
How would you code the following: Invasive adenocarcinoma of the descending colon. Robotic assisted laparoscopic right colectomy with intracorporeal ileocolic anastomosis/Intraoperative mesenteric angiography. Abdomen prep draped standard surgical fashion vs needles and trocars placed entry to the abdominal and pelvis exploration performed. Using a medical to lateral approach, we mobilized the mesentery to the right colon off the retroperitoneal structures including the duodenum and kidney safely. High ligation of the ileocolic artery was performed with the vessel sealing device. We took down the hepatic flexure transected the midtransverse colon area. We mobilized the terminal ileum with the right lateral gutter and transected the terminal ileum area. Took down the remaining attachments of the right colon plate it above the liver temporarily. We then performed intraoperative mesenteric angiography using the Firefly system. Anesthesia injected tml of indocyanine green using the Firefly system. Confirm excellent profusion of the staple lines. We then performed isoperistaltic ileocolic anastomosis and aligned the antimesenteric borders with 3.0 Vicryl suture. Enterotomy and colostomy was made extractic the right colon removing specimen. Then all the closures were made.

I also believe that the provider needed to add more specifics to that procedure.

CPT code for Lap colectomy 44204, however don't have CPT code for the mesenteric angiography.

A surgical coding specialist in Arizona

Response:
According to the US National Library of Medicine, Mesenteric angiography, also known as Mesenteric arteriography, is used to view blood vessels that supply the large and small intestines. Typically, this procedure is performed to determine where an artery is blocked or bleeding using injected contrast to highlight arteries in the intestine.

Based on the operative report documentation and the location of the mesenteric artery, CPT coding would fall within Aortography, code range 75600–75630, with code 75726, angiography, visceral, selective or supraselective being the optimal code.

Sources: https://medlineplus.gov/ency/imagepages/9623.htm; American Medical Association CPT, 2018 Professional Edition; and Elsevier's Anatomy Plates, Circulatory System, arteries of the abdomen and pelvis.

— Karla VonEschen, CPC, is a coding analyst at 3M Health Information Systems.