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Briefing: MHS Coding Case Studies Date: 20 March 2007 Time: 1610 - 1700

Briefing: MHS Coding Case Studies Date: 20 March 2007 Time: 1610 - 1700. Objectives. Make audience aware of migration from the UB-92 to the UB-04 and its impact Contrast civilian coding conventions with those of the MHS Provide coding practice with real life scenarios

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Briefing: MHS Coding Case Studies Date: 20 March 2007 Time: 1610 - 1700

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  1. Briefing: MHS Coding Case Studies Date: 20 March 2007 Time: 1610 - 1700

  2. Objectives • Make audience aware of migration from the UB-92 to the UB-04 and its impact • Contrast civilian coding conventions with those of the MHS • Provide coding practice with real life scenarios • Highlight information from MHS Coding Guidelines

  3. MHS Coding Case Studies Data Elements on the UB-04: • UB-04, Reason for Visit, Present on Admission revisions go into effect for the submission of claims 23 May 2007 • A new UB-04 data element is the Present on Admission (POA) indicator. Its purpose is to differentiate between conditions present at admission and conditions that develop during an inpatient admission • The Agency for Healthcare Research and Quality (AHRQ) has stated that use of the POA indicator will provide better outcomes for patient and improve healthcare —Continued—

  4. MHS Coding Case Studies • POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter such as the initial emergency department visit, or during observation are considered as present on admission • The UB-04 revisions apply only to paper claims submissions. POA indicators apply to both principal and secondary diagnoses fields • The reason for visit is required for all unscheduled outpatient visits/bills with associated revenue codes 45X, 516, 526 • The reason for visit can have up to three ICD-9-CM codes listed

  5. MHS Coding Case Studies Case Study #1 – POA • 80-year-old female patient presents to the ED from the nursing home with a ever of 101.9, severe cough, dehydration and difficulty breathing. Following her 5- day hospital stay a,nd work up, the physician documents the primary diagnosis as “Small cell carcinoma of the right lung.” Is the small cell carcinoma of the right lung a POA?

  6. MHS Coding Case Studies Case Study #2 – POA • 52-year-old male is admitted for total hip replacement due to complication from osteoarthritis. Following surgery, he develops a pulmonary embolism. What are the correct assignments for POA?

  7. MHS Coding Case Studies Case Study #3 – POA • 62-year-old female is admitted from the physician’s office for a high fever and pneumonia. The patient’s condition declines during her hospitalization and she becomes septic according to the physician progress notes. The physician’s discharge summary lists “Sepsis” as the primary diagnosis and “Pneumonia” as a secondary diagnosis. What are the correct POA assignments?

  8. MHS Coding Case Studies Case Study #4 – POA • 21-year-old female is admitted to the hospital for induction of labor at 42 weeks gestation, and undergoes a normal delivery. What is the correct POA assignment?

  9. MHS Coding Case Studies Case Study #5 – POA • 25-year-old female is admitted to the hospital in active labor. Following a normal delivery, the patient develops a fever, high white blood cell count, and a chest x-ray positive for pneumonia. What is the correct POA assignment?

  10. MHS Coding Case Studies Case Study #6 – Reason for Visit • 70-year-old male presents to the emergency room for shortness of breath and chest pain. Following examination, he is discharged with a diagnosis of musculoskeletal pain due to over exertion while working in his garden. What is the reason for visit?

  11. MHS Coding Case Studies Case Study #7 – Reason for Visit • 25-year-old female reports to the hospital-based urgent care clinic for headache. Following examination, she is discharged with a sinus infection. What is the reason for visit?

  12. MHS Coding Case Studies Case Study #8 – Reason for Visit • A patient with a known history of asthma comes into the emergency department (ED) complaining of shortness of breath. The ED physician documents Acute Asthma Exacerbation as the final diagnosis. How would you code the reason for visit?

  13. MHS Coding Case Studies Case Study #9 – Emergency Department (ED) • A patient is seen in the emergency department with a diagnosis of ingestion of poison. The emergency department physician performs gastric intubation, aspiration, and lavage, and completes a detailed history and comprehensive exam with high-complexity decision making • As coder for the emergency department physician, you assign the appropriate codes

  14. MHS Coding Case Studies Case Study #10 – ED • A patient was seen in the ED after cutting her finger with a paring knife. The provider sutures the 2.5 cm laceration with a layered closure • According to the acuity level tool, this is a Level I encounter • What is the correct CPT code assignment for this encounter?

  15. MHS Coding Case Studies Case Study #11 – ED • 72-year-old Medicare patient presents to the emergency department for a 2.0 cm superficial laceration of the upper arm, caused by a hoe in his backyard garden. With the use of Dermabond tissue adhesive, the provider approximated the wound edges and dressed the wound • What are the correct code assignments?

  16. MHS Coding Case Studies Case Study #12 – ED • 10-year-old boy was seen in the emergency department after stepping on a piece of glass in the public playground. The wound required prolonged cleansing due to the amount of dirt and grass embedded in the skin. A single-layer wound repair using 6 stitches was performed. What are the correct code assignments?

  17. MHS Coding Case Studies Case Study #13 – ED • Medicare patient presents to the emergency department after falling down a flight of stairs. The physician evaluates the patient's injuries: 2.0 cm laceration of elbow, abrasions on the knee and forearm. The patient explains that she felt dizzy before the fall, and the physician evaluates the problem. X-rays and laboratory tests are normal. The physician sutures the simple laceration

  18. MHS Coding Case Studies Case Study #14 – Clinic visit • A patient with an acute exacerbation of asthma is seen by family physician and has a detailed history taken; an expanded, problem-focused, exam done; and low level medical decision-making used. The patient expresses a desire to quit smoking and receives 30 minutes of initial treatment in a smoking cessation program and a 1-week supply of nicotine gum. How is this visit coded?

  19. MHS Coding Case Studies Case Study # 15 – Clinic visit • 49-yr-old retired beneficiary has been evaluated over 3 months (5 visits) for intermittent joint pain, intermittent vertigo, and severe fatigue. Patient says he believes he was exposed to something in Kuwait on mission two years ago. Work-up to date is complete, but negative

  20. MHS Coding Case Studies Case Study #16 – Clinic visit • S: This established 29-year-old patient of mine comes in today because yesterday she was playing with her cat and the cat bit her left forearm. She states she started feeling feverish and noticed increased redness last night and this morning. She has had no joint pain with this • O: Temp 99.2 degrees, pulse 68, resp 20, weight 142. Left arm reveals four puncture wounds with secondary cellulitis around the area. The area is warm to the touch and is erythematous. • A: Infected cat bite • P: The patient is put on Erythromycin 333 mg t.i.d. for 10 days and given 1 gram of Rocephin IV today. Follow up in 24 hours. A bandage was applied. The cat is up to date on his shots, and she states that she had provoked the cat. Her last tetanus was over ten years ago, so she was given a tetanus booster today. She will use Tylenol as needed for pain • History: Expanded problem focused • Examination: Problem focused • Medical Decision Making: Moderate

  21. MHS Coding Case Studies Case Study #17 – Clinic visit • Clinic Progress Note, Eye Examination: • Today I saw Jay, who is now 21 years old. I last saw him 6 years ago when he had a corneal ulcer on his right eye. This is now cleared, and he has noticed that he cannot see well • The patient has a normal corneal anterior chamber and iris but with very slow dilating pupils. There is no pseudoexfoliation, but there are dense juvenile nuclear cataracts on both eyes; the right greater than the left. I counseled him for cataract surgery of this right eye first, and then the left eye, the need for postop correction, a 4- to 6-week recovery time, and the type of procedure; we will see him in surgery on the last Monday of the month

  22. MHS Coding Case Studies Case Study #18 – Clinic visit • While chasing his brother, this 13-year-old male fell through a sliding glass door and sustained three lacerations: one on his left knee, one on his right knee, and one on his left hand • Left knee: 5.5 cm laceration involving deep subcutaneous tissue and fascia, repaired with layered closure • Right knee: 7.2 cm laceration repaired under local anesthetic, with a single-layer closure • Left hand: 2.5 cm laceration of the dermis, repaired with simple closure under local anesthetic • Assessment: Wounds of both knees and left hand require suture repair using 1% lidocaine for local anesthetic • Plan: Follow-up in 10 days for suture removal. Call office if there are any problems or complications

  23. MHS Coding Case Studies Case Study #19 – Clinic visit • An AD member who recently returned from deployment presents to clinic for an evaluation of a rash. The provider evaluates the patient and diagnoses the patient with cutaneous leishmaniasis related to his recent deployment to Iraq • The primary diagnosis? • The secondary code?

  24. MHS Coding Case Studies Case Study #20 – Clinic visit • Physical Therapy evaluation • Patient is referred to the local rehabilitation clinic by family physician for a physical therapy evaluation after a knee repair. Patient has degenerative osteoarthritis. The physician provided the evaluation and a written report was developed

  25. MHS Coding Case Studies Case Study #21 – Clinic visit • CC: Podiatry follow-up • S: The patient is a 46-year-old diabetic with complaints of a painful foot. She neurologically has loss of feeling that is consistent with neuropathy • O: She has an arthritic spur on the dorsum of the left foot which has been controlled in the past by trigger point injection therapy. Here today for injection only • A: Arthritic exostosis and diabetic neuropathy • P: Trigger point injection of 1 cc of 0.5% Sensorcaine to the dorsum of the left foot done today • Will follow with PCP next week and return to me on next episode of foot pain

  26. MHS Coding Case Studies Case Study #22 – Clinic or APV • LASIK – Pre-op: • Diagnosis 1: V72.83 Other Specified Pre-Op Exam • Diagnosis 2: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. • E&M 99499 • Procedure Code(s) as applicable: • 92004 Comprehensive New or 92014 Established • 92015 Refraction (can only use once) • S0820 Computerized Corneal Topography (New CPT code 92025 will be available in future AHLTA upgrade) • 76514 Pachymetry (no 50 modifier, bilateral code)

  27. MHS Coding Case Studies Case Study #22 – Clinic or APV • LASIK – Intra-operative: • Diagnosis: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. • E&M 99499 • Procedure Code(s) as applicable: S0800 LASIK S0810 PRK • Use 50 modifier for bilateral • Use 54 modifier only surgery performed at MTF • DO NOT use code 65760 Keratomileusis or 92070 Therapeutic CL • 99199 is performed as an APV

  28. MHS Coding Case Studies Case Study #22 – Clinic or APV • LASIK – Post-op: • At same MTF: • Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa •     E&M: 99499 •     Procedure Code: 99024 • At different MTF: • Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa •    E&M: 99499 •    Procedure Code: S0800 or S0810 with 55 modifier for first f/u encounter, subsequent encounters 99024

  29. MHS Coding Case Studies Case Study #23 – Inpatient • Scenario: This 21-year-old gravida 1 para 1, by cesarean delivery, presented to the emergency department in active labor. She was 38 weeks’ gestation, visiting her parents 250 miles from her home. Patient delivered vaginally in the elevator on the way to obstetrics. The emergency services physician, Dr. Scott, delivered the baby. An obstetrician, Dr. Dan, delivered the placenta. The patient will follow up with her obstetrician for postpartum care • A: What CPT code(s) should Dr. Scott report for the vaginal delivery? • B: In the above scenario, what CPT code(s) should Dr. Dan use to report delivery of the placenta?

  30. MHS Coding Case Studies Case Study #24 – Inpatient • A patient is admitted for a scheduled cesarean section • Preoperative Diagnosis: Previous C/S • Postoperative Diagnoses: • Previous C/S • Macrosomia • Breech • Procedure performed: Repeat low transverse cesarean section • Findings: Viable infant male with Apgars of 8 and 9. The infant’s weight is 4206g. Maternal anatomy normal, including uterus, ovaries, and tubes. She did have significant scarring and adhesions in the subcutaneous tissue as well as subfascially

  31. MHS Coding Case Studies Case Study #25 – Inpatient • Patient with menorrhagia is admitted to GYN for planned hysterectomy. Hysterectomy was performed the day of admission. It was determined that uterine fibroids were the cause of menorrhagia

  32. MHS Coding Case Studies Case Study #26 – Inpatient • Patient was admitted to family practice with abdominal pain. General surgery consulted on day 3 of admission and determined a diagnosis of appendicitis. Care was transferred to general surgery. On day 3, an appendectomy was performed

  33. Quiz • When is POA defined? • A civilian ED encounter does not require an E&M code under what circumstances? • LASIK is coded using what type of code? • Does the MHS use global OB codes? • Rounds are considered what type of services?

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