Thursday, August 25, 2011

Infant and Adult Circumcision Coding: Understanding the procedures and how to code them.

Infant and Adult Circumcision Coding: Understanding the procedures and how to code them.

When most of us hear the word circumcision, we immediately think about the procedure as performed on infants. Those of us that work in the urology field, have realized that circumcisions are performed on all ages, for many different reasons. Most often, circumcision is performed for religious, or cosmetic reasons. However, there are instances when it is medically necessary to have a circumcision performed. Most circumcision revision cases are required to repair side effects of disease, or surgical complications from previous surgery or trauma to the penis.

CPT-4 denotes the circumcision codes as those between 54150 and 54163; ICD-9 denotes the circumcision as code 64.0, code 64.49 as a repair of the penis, and V64.93 as a division of penile adhesions. As we transition to ICD-10PCS, I have cross coded the ICD-9 procedure codes in the table below. As you begin working more with I-10 you will become more familiar with the procedure codes/codesets. The GEMS mapping tables can be utilized, but many coders have found them to be inaccurate.
64.0 OVT|T|X|Z|Z
64.49 Multiple code choices
64.93 OVN|T|X|Z|Z

Circumcision Background:

Routine circumcision at birth for non-religious reasons is a common custom in the US and Canada. A parents’ wishes are varied as to whether or not to circumcise at birth. Circumcisions are frequently performed 24 hrs to 10 days after birth. Religious reasons for circumcision are very personal and for those cases it can be a ‘mandatory’ procedure regarding one’s faith. Religious reasons may dictate the timeframe, and it may vary as to when the procedure is performed, and by whom.

Medical necessity can also be a driving force for a newborn circumcision. However, medical necessity is a more common reason in adult or non-newborn circumcision(s), than cosmetic or routine circumcision. Adult circumcision can be performed strictly for cosmetic reasons, if the patient is unhappy with their current anatomical status. The most common medically necessary circumcision diagnosis is for a tight frenulum, balanitis, or a phimosis. If left untreated, penile cancer has been noted in men with long-standing untreated balanitis or phimosis. I

In cases of premature newborns, a circumcision procedure may be delayed until the patient is able to undergo the procedure by achieving a reasonable body weight and is no longer considered ‘at risk’ due to prematurity.

Basic Circumcision Procedure Code Details

The circumcision for an infant is a relatively simple procedure, and is denoted by the use of CPT code 54150/ICD-9 procedure code 64.0. A device such as a gomco clamp, or plastibell is used to remove the redundant skin and foreskin in a relatively quick excision type procedure. The clamp also stops the bleeding and bonds the edges of the skin together. Normally no sutures are needed. This type of procedure is commonly performed on the newborn by a pediatrician, a general or family practice physician, and sometimes even the OB physician. The parent of the newborn may also choose to have a urologist or even a member of the clergy to perform a circumcision.

CPT code 54160 denotes ‘surgical excision other than’ clamp, device or dorsal slit for infants 28 days or less, CPT code 54161 is for usage on patients above the age of 28 days. This code is more commonly used by urologists. Most urology practitioners prefer a surgical procedure, over usage of a device or clamp. The surgical excision procedure denoted by codes 54160/54161 provides a more precise excision of the excess skin, and oftentimes a better cosmetic outcome. If you are coding from the ICD-9 procedures, it does not differentiate between a surgical excision or one that uses a clamp or device.

Another key piece to the coding of a straightforward circumcision is the diagnosis. If the reason for the circumcision is a routine, cosmetic, religious or ritual circumcision the code V50.2 should be appended. However, if the circumcision is performed for a medically necessary reason, do not use V50.2. Use a diagnostic code to append with the claim such as balanitis, phimosis, or a penile anomaly.

Post circumcision revisions and repairs.

As with any surgical procedure, sometimes the outcome is not perfect. Circumcision surgery is no different. CPT-4 guides the coder to use code 54162 and ICD-9 directs the coder to use 64.93 for the lysis or excision of post-circumcision adhesions. It is interesting that ICD-9 describes the procedure as a ‘division of penile adhesions’, whereas CPT4 describes the procedure as ‘lysis or excision’ of post-circumcision adhesions. Another term you may hear or see in the operative report refers to a post-circumcision skin bridge. This is also a complication or late effect from the original circumcision procedure.

If the physician is repairing or revising and incomplete circumcision, CPT-4 directs us to use code 54163. It is important to note, that ICD-9 procedure codes do not have a separate code for this procedure. You will still need to use code 64.0. Careful review of the code verbiage and procedure documentation should be done by the coder. If unclear, be sure to query the physician for clarification.

One issue that has come up repeatedly is the coding and billing of the penile dorsal nerve block as anesthesia during circumcision. CPT allows for this procedure with code 64450, and appended with modfier -47 to indicate anesthesia by the physician performing the procedure. However, insurance payers and carriers may consider this a bundled procedure with a circumcision. As a coder, you will need to check the CCI bundling edits, and/or the 3rd party insurance carrier coding edits to see if they allow for payment of this anesthesia procedure in coordination with the circumcision. If the payer considers this anesthesia injection ‘bundled’, then it should not be billed. If you are unable to ascertain if payment by an insurance carrier is allowed, have the guarantor or patient sign an advance notice of non-coverage and collect for payment up front. Many 3rd party payers will not pay for a circumcision if it is for routine, ritual, religious or cosmetic reasons. Therefore, collecting payment for the procedure(s) and supplies up front is ideal.

The Operative Reports
In the case studies below, you can review these operative reports to fully understand the differences between the circumcision procedures, and the CPT and ICD9/ICD-10 procedure and diagnosis reporting codes.

Operative Case #1 Circumcision – Neonatal Procedure::
The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The 2 day old infant was placed on the papoose board.

Procedure Detail: The external genitalia prepped with Betadine. A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine. Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. The incision was made. The appropriate size bell was obtained and placed over the glans penis. The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco. The bell was then placed and tightened down. Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. A blade was used to incise circumferentially around the bell. The bell was removed. There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed. Vaseline gauze was then placed.

CPT Procedure: 54150 ICD-9 Procedure: 64.0 ICD-10 Procedure: OVT|T|X|Z|Z
ICD-9 Diagnosis: V50.2 ICD-10 Diagnosis: Z41.2

Operative Case #2 Post Circumcision Lysis of penile Adhesions

CC Office Visit/procedure Surgical followup of circumcision – lysis of adhesions.

HPI: The patient had his circumcision performed on 09/16/20XX at 4 months of age due to an extensive phimosis. The original circumcision was successful other than a little bit of bleeding upon awakening in recovery room. The post-op bleeding required placement of some additional sutures, but after that, his recovery has been complete.

Exam/Procedure: Today, we are 30 days post operative and patient looks healthy and happy. I examined his circumcision site. The monocryl sutures are still in place. The healing is excellent, and there is only a mild amount of residual postoperative swelling. There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today with a mini scalpel after application of topical anesthetic. Antibiotic ointment was then applied.

IMPRESSION: Satisfactory lysis of adhesions post circumcision for severe phimosis

CPT Procedure: 54162 ICD-9 Procedure: 64.93 ICD-10 Procedure: OVN|T|X|Z|Z
ICD-9 Diagnosis: 605 ICD-10 Diagnosis: N47.5

Operative Case #3 Adult Male Circumcision
PREOPERATIVE DIAGNOSIS: Bacterial Balanoposthitis , phimosis.and Penile Edema
ANESTHESIA GIVEN: 30 cc of 0.25% Marcaine (plain) as a field block at the base and with a portion distributed at the frenulum; monitored anesthesia care and then general anesthesia with LMA.
FINDINGS: The patient was found to have massive edema of the foreskin without any evidence of purulence. No inflammatory changes were noted involving the glans penis.
DESCRIPTION OF THE PROCEDURE: After satisfactory placement in a supine position, the patient was induced with deep sedation. The MAC was provided by Dr. Abc, and was maintained throughout the procedure. I injected 30 cc of 0.25% Marcaine plain at the base of the penis and at the area of the frenulum. The area was prepared with thick jelly Betadine for good penetration and to keep the pubic hair away from the operative area. Dorsally, a straight clamp was passed across the edematous foreskin beginning at the level of the phimosis and the tissue was crushed. Along this relatively avascular line, the fine Metzenbaum scissors were used to divide the tissue to within about one centimeter of the glans. Similar incisions were made at three o'clock and nine o'clock and this produced wings of redundant markedly edematous penile skin. We were surprised to find no evidence of purulence and no inflammation of the glans penis nor the mucosa. A number of small bleeding points were noted around the shaft. These were clamped with fine hemostats and electrofulgurated. Fine chromic sutures were placed to provide complete hemostasis. The cut edge of the mucosa and the skin was then reapproximated with interrupted vertical mattress and horizontal mattress sutures of 2-0 chromic. Resolution of the bleeding and the swelling responded well to gentle pressure. Application of an antibiotic ointment, Xeroform gauze, and a circumferential gentle pressure dressing were provided. The patient was taken to the recovery area in satisfactory condition.
CPT Procedure: 54161 ICD-9 Procedure: 64.0 ICD-10 Procedure: OVT|T|X|Z|Z

ICD-9 Diagnosis: 607.83
ICD-9 Diagnosis: 607.1
ICD-9 Diagnosis: 605

ICD-10 Diagnosis: N48.89
ICD-10 Diagnosis: N47.6
ICD-10 Diagnosis: B96.89
ICD-10 Diagnosis: N47.1

It’s a mans world… Coding for vasectomy

It’s a mans world… Coding for vasectomy

When looking at vasectomy codes in the CPT book, it seems like a very straightforward type of procedure. Upon closer review, a coder really has more choices that what is readily apparent.

A vasectomy is a permanent form of birth control or sterilization for a man, and can be performed in as little as 30-40 minutes. Vasectomy procedures are routinely performed in a variety of settings such as a physician office, outpatient clinic or even an ambulatory surgery setting. The majority of vasectomy procedures are performed in a physician office.

The most commonly performed vasectomy procedure is the traditional vasectomy designated by CPT code 55250. ICD9 Vol 3 procedure code lists this as 63.73. A newer approach for vasectomy is referred to as the ‘no-needle, no scalpel” and this procedure is primarily coded with CPT code 55450, ICD-9 Vol3. as 63.71. Physicians can also perform a laparoscopic vasectomy, although this is the least commonly performed vas procedure. A laparoscopic vasectomy is usually performed in conjunction with another procedure such as an inguinal hernia repair, therefore avoiding an additional incision for the vasectomy. CPT has not designated a specific code for a laparoscopic vasectomy, so it would be appropriate to use code 55559 unlisted procedure on spermatic cords, in addition to the primary laparoscopic code. ICD-9 Vol3 directs us to use 63.99 as other operations on the spermatic cord, epididymis, and vas deferens.

As a coder, it is important for you to understand what is involved with the procedure itself for successful code designation. Understanding and recognizing the surgical approach of the procedure detailed in the operative note is the critical piece of the coding puzzle.

“Traditional” Vasectomy
The “Traditional” vasectomy procedure code 55250 is an open-style procedure which involves a direct incision performed on the side of the scrotum, after an injection of anesthesia to the surrounding area or a nerve block injection is performed. The vas deferens is then pulled up and inspected visually. The physician will ether cauterize, cut, tie off, or occlude with clips or implants to the vas itself. The Vas deferens is then placed back into the srotum and the open incision is stitched or sealed with dermabond, in some cases the physican may only place a bit of surgi-tape or a butterfly-type bandage. The traditional vasectomy can be performed in the physicians office, or an outpatient clinic or ambulatory surgery center.

No Needle No Scalpel Vasectomy
In the case of a ‘no-needle no-scalpel’ procedure the procedure is very similar to the open procedure, however it is performed as a percutaneous entry into the scrotum. The no-needle portion of this is in reference to the anesthesia. The physician uses a directed high pressure jet injector system to deliver the anesthesia prior to the procedure. The no-scalpel portion refers to the instrumentation being used. These special instruments are similar to a small punch or puncture type procedure resulting in a ‘hole’ in the scrotum rather than the traditional ‘incision’. Again, the physician gently pulls the vas deferens out of the hole and ether cauterizes, cuts, ties or occludes the vas with clips or occlusive implants. This procedure can be performed in the physician office, or outpatient clinic or ambulatory surgery center.

Laparoscopic Vasectomy
The laparoscopic vasectomy is not normally performed by itself. It is usually performed in conjunction with another laparoscopic procedure performed on the same day. When this type of vasectomy is performed, CPT and ICD-9 Vol3 have not designated a specific procedure code for this. The laparoscopic vasectomy also severs the vas deferens, but again, it is the surgical approach that differentiates what code you should append. As a coder you should append the unlisted code(s) of 55559 or V63.99. As with any unlisted type procedure, be prepared to forward copies of the operative note and medical necessity documentation to support your claim for payment of an unlisted procedure to the 3rd party insurance carrier.

The Diagnosis Connection
As with any procedure the diagnosis is an integral part of the case. Diagnosis code V25.2 should be appended to the vasectomy sterilization procedure. However, if the procedure is being performed for a medical, or therapeutic reason, such as groin pain, the diagnosis should reflect that.

What else do you need to know?
Evaluation and Management or Sterilization Consultations performed by the physican on the same day as the procedure itself require usage of the modifier 25 to your insurance claim. Modifier 25 is necessary to support the documentation for a separately identifiable service. In addition, billing for surgical trays and local anesthesia supplies are commonly considered ‘bundled’ by most insurance payers with the vasectomy procedure itself.

Post operatively, a semen or sperm count will need to be performed before the patient can be deemed ‘sterile’. Normally 3 separate sperm counts will be performed post procedure over the course of 90 days. These tests are considered ‘bundled’ with the vasectomy procedure. It is inappropriate to bill these as a separately identifiable service to the patient or the insurance carrier.

Do not use modifier -50 if a vasectomy is performed as a bilateral procedure. CPT notes in the verbiage of the code descriptor code is applicable when performed as a unilateral or bilateral procedure. By the same rationale, do not use a modifier 52 if the procedure is only performed unilaterally or on one side only.

Insurance carriers have many differing policies in regard to payment for an elective vasectomy, when performed for sterilization. It is advisable to pre-authorize any vasectomy procedure with the insurance carrier. If the carrier does not provide coverage or payment for a vasectomy service, then payment should be collected directly from the patient. However, some 3rd party insurance policies do cover sterilization procedures, but if you cannot get a pre-authorization from the carrier, an advance beneficiary notice should also be obtained.

The operative reports:

Op Report – Tradtional Vasectomy
REOPERATIVE DIAGNOSIS: Voluntary sterility.
OPERATIVE PROCEDURE: Bilateral vasectomy. ANESTHESIA: Local.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the procedure table. Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. A small incision was made in the right hemiscrotum. The vas deferens was grasped with a vas clamp. The vas deferens was skeletonized, clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. The same procedure as above was performed on the left hemiscrotum without complication. A jockstrap and sterile dressing were applied at the end of the case. Sponge, needle, and instruments counts were correct.

Op Report No-Scalpel Vas

PREOPERATIVE DIAGNOSIS: Desire for sterility.
POSTOPERATIVE DIAGNOSIS: Desire for sterility.

DESCRIPTION OF PROCEDURE: The patient was brought to the suite, where after oral sedation, the right and left scrotum prepped and draped. Then, 1% lidocaine was used for anesthesia though mada-jet. . The right vas was identified by palpation, scrotal skin was punctured with the no scalpel instrumentation device and used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the left side. Patient to recovery in good condition.

Sunday, August 21, 2011

ICD-10 Training Update II

Good News for those that follow my blog... After aprox 20 hrs of testing, I passed the National AHIMA ICD-10 Trainer's test. I am now officially recognized as being able to TEACH ICD-10CM and ICD10PCS!!!


It was a tough test, but by following the rules and conventions set forth, it begins to make sense after all.

I am very grateful to the Idaho chapter of AHIMA, as they provided a scholarship for me to attend the training in Cour d'Alene, Thanks go to my employer and manager for allowing me the time off to attend, study and take the test. Most importantly, a big THANK YOU to my family, friends and coding peers for the encouragement and help.

Next - the work begins with training and preparing for the transition. Scary but exciting!. Stay tuned, and I'll be posting now with addidtional helps & hints for the ICD-10 transition!