Saturday, April 5, 2014

Documentation Challenges for Integumentary/Skin and Dermatology Coding

A quick refresher on dermatology coding documentation!!!

Dermatology coding seems to be fraught with many difficult aspects for coders that have to code from the integumentary system.  This can range from misunderstanding benign, malignant, and uncertain behavior, lesion, mass, Shaving, biopsy, destruction, simple, intermediate, complex repair, and sizing such as length, depth, width, circumference, elliptical, and don’t forget knowing the differences between centimeters (cm) and millimeters (mm).  As expected dermatology specialty coders are very adept at easily coding within this section, but coders who are proficient in a specialty that occasionally touches this area, such as Urology, Gynecology and Family Practice, may have more difficulty with this section of CPT.

Dermatologists are very adept at getting their coders what they need to code correctly, but for the other providers of care, this may not be the case.  Coders that need to code dermatology related procedures need to have a good understand of what a skin condition really is.  Documentation by the provider is very helpful, but having a good understanding of what the physician documents and how the coder interprets that documentation is a critical and key component to successful coding.  Common skin condition terms may be used, the list below outlines conditions commonly noted in patient record documentation.

Common Skin Condition terms:

Atrophic = Thin, wrinkled
Blister = fluid filled bump
Crust/scab = formation of dried blood, pus or other skin fluid over a break in the skin
Excoriation = a scratch
Hives/Wheals = a pink or white swelling of the skin
Lichenification = Skin that has become thickened, hardened or leathery
Macule = a flat, discolored spot
Nodule/Papule = solid raised bump(s)
Raised bumps = bumps that stick out above the skin surface
Patch = flat discolored spot/area
Pustule/Pimple = Inflamed, elevated lesion that appear to contain flue or pus
Scales = dead skin cells that form flakes
Scar/Cicatrix = fibrous tissue that forms after a skin injury
Keloid scars = Thick, rounded, or irregular clusters of scar tissue that grow at the site of a wound on the skin
Port Wine Stain = congenital capillary malformation
Hemangioma = Vascular birthmark
Telangiectasia = small blood vessels that are located under the surface of the skin.
Warts = growths of skin or membrane that are not malignant
Hidradenitis = Inflammation of the sweat glands

Documentation areas of concern are also made more difficult if the physician or provider does not give a good clear description of the procedure being performed.  The physician may state that they are going to biopsy a lesion, when in essence; they really are performing a “shave”.  If you, as a coder are unclear regarding the documentation, query the physician, and ask for clarification to be amended to the note.  Once that is completed, then code then bill your claim to the insurance carrier.  Being aware of the financial reimbursements is critical for coders.  The RVU’s for the biopsy code 11100 may be more or less than the RVU's attached to a shave removal code.  It is in the best interest of all to accurately record what was performed by the provider.  By coding accurately with the most accurate and appropriate procedure codes, reimbursement can be expedited.  If by chance reimbursement is denied, then your documentation will support all that is coded and billed.  In the scenario below, the unacceptable documentation is from an actual case study from a family practice chart.

Unacceptable Documentation:  A quick biopsy was performed on both lesions; left calf and right thigh, above the knee.  Biopsy site checked for bleeding.  Hemostasis was achieved, a local antibiotic was placed and the site was bandaged.  Both specimens sent to pathology.

Acceptable Documentation:  A quick biopsy was performed on both lesions; left calf and right thigh above the knee. Lesion on the left calf was 1.0 cm and completely shaved (CPT code 11301)  The lesion on the right thigh is 1.2 cm.  A 3mm punch was used to biopsy this lesion. (11100) All sites checked for bleeding.  Hemostasis was achieved, and a local antibiotic was placed on each site and bandaged.  Both specimens sent to pathology.

In the examples above, a coder would have a very hard time accurately coding what the physician performed.  By having the physician notate just a bit better, it clearly reflects what was performed (eg. the “shave removal” of the complete ankle lesion, and the “punch biopsy” of the lesion on the thigh).   Of course, as a coder you always have to remember the modifiers to accurately “unbundle” the separately identifiable lesions.  Carefully review modifiers 51, 59, RT and LT just to ensure that your coding is up to par.

Hidradenitis – A commonly mis-coded condition

Hidradenitis is commonly incorrectly documented and or mis-coded.  Hidradenitis is simply an inflammation of the sweat glands.  In regard to Hidradenitis, a physician may simply states what he documents as a sign or symptom rather than a definitive diagnosis.  Oftentimes, Hidradenitis is referred to as an ‘abscess’ in the underarm area, and does not state that the condition is a Hidradenitis.  As a coder, you may be unaware that CPT codes 11450 - 11471 are used for the specific treatment of hidradenits for excision and repair.  CPT code 10060 incision and drainage of abscess also refers to Hidradenitis.  If you suspect that the patient may have Hidradenitis, but the physician has not documented it, a quick query will clear up the confusion.  The CPT lay description notes it as

…..” a chronic suppurative disease that produces scarring of the skin and subcutaneous tissue. Clinically visible are at least two blackheads with several surface openings, subcutaneous communication, and subsequent abscess formation in the axillary region. The abscesses lead to extensive scarring of the dermis. The physician performs a wide excision of the abscess. The excision site is left open to heal by granulation or may be sutured simply or in layers for 11450. Report 11451 if complex repair requires local pedicle flap coverage or skin grafting.”

In addition, this condition is reported with ICD-9 diagnosis of 705.83 and in ICD-10cm as  L73.2

CPT has specific codes for the treatment of hidradenitis using excision and repair (codes 11450 – 11471) .  However, if the physician is simply performing an incision and drainage of the hidradenitis, then CPT codes 10060-10061 would be appropriate.  If you do not use CPT for your procedure codes and utilize ICD-9 Vol3, Code 86.3 and will be using ICDd-10pcs 0HB5XZZ

Operative Case Study: Excision of bilateral chronic hydradenitis.
Patient had previous excision of axillary hydradenitis x 2 years ago,  however, had residual disease in both axilla with chronic re-draining of the cyst from hydradenitis. There is an area in each axilla which is to be excised today.

PROCEDURE: Under local infiltration with anesthesia, an elliptical incision is first made on the left side to encompass the area of chronic hydradenitis of 3.5 cm by 4 cm. Wound was then irrigated with saline. The the wound was closed utilizing a layered closure with interrupted 3-0 Vicryl. The skin layer itself was closed using interrupted 5-0 nylon.  Attention is now directed to the right side where a similar procedure was carried out encompassing the involved area measured as 2.3 cm x 4 cm with the closure being identical to the opposite side. All of the active areas of hydradenitis were completely excised.

In this case study, it would be appropriate to code/bill with either of the CPT choice scenarios outlined below.

CPT (Choice #A) 11450.50
(bilateral modifier Modifier 50 as the Bilateral Modifier to designate procedure performed on both right and left axilla

CPT (Choice #B) 11450.RT
 11450.51.LT   Modifier 51 as the second procedure performed, with designation of RT and LT.

DX: 705.83 ICD-9 L73.2 ICD-10cm

Wound/Lesion Documentation

Wounds, Lesions and skin injuries are very common occurrences that are treated by all types of specialties not just in a dermatology specialty.  When providing care for these type of issues, a detailed description is very helpful.  The list below is very helpful for coders to review and share with the providers.  It makes coding much easier when a full “picture” of the procedures was clearly defined.  Here’s a quick listing
1) Location:  Documentation of the exact area and location where the lesion or wound is located.
a) Left calf, right upper arm, face above left eyebrow etc…

2) Size: Document the measurements of the wound or lesion(s)
a) Measure the length (vertically) of the wound at its longest point.
b) Measure the width (horizontally) of the wound and record these numbers
c) Measure the circumference  (around)
i) . This information will be used to determine whether the wound is growing or getting smaller over time.
d) Measure the depth of the wound in terms such as millimeters or centimeters, or if included subcutaneous tissue, muscle or fascia, etc… (usually to be noted post excision or biopsy)

3) Symmetry and appearance:  Document if the wound or lesion has symmetrical or asymmetrical/irregular borders, or a raised or flat appearance, pustular, or hard, horn shaped etc…

4) Characteristics: Document the characteristics of the lesion/wound, such as color, odor, draining, (eg reddish-purple nodule, green tinged  odorless drainage, brown foul smelling pus )

5) Tissue type: Document if the tissue is granulating, keloidal, friable, necrotic. in addition to drainage or odor.
a) Different areas of a wound or lesion may contain different types of tissue.  If possible have the provider make a rough sketch of the lesion and/or wound.  Even better is if a digital or instant photo is recorded of the lesion and placed in the documentation

6) Document specific treatment provided  during the encounter:
a) Incision and Drainage
b) Excision of lesion/wound via Shave, scalpel,
c) Biopsy using punch, or excision
d) Destruction via laser, cryosurgery,, chemical, thermal, laser

7) Benign or Malignant: Review the documentation to verify from pathology if the lesion or wound is benign or malignant.
a) If not noted, wait until you receive a pathology report before coding.
b) If not sent to pathology, code as “benign”

8) Repairs: Simple, Intermediate or Complex, make sure the documentation supports a simple, intermediate or complex repair.
a) Don’t code for a complex repair if the documentation supports only a simple repair.
b) CPT has very clear guidelines for documentation of simple, intermediate and complex repair criteria.

The bottom line to successful documentation and coding for Integumentary/Skin and dermatology areas remain good communication between the coder and the provider of care.  When in doubt, hold your code until you can clarify what was actually performed, then ask your physician to amend or clarify within the record what was performed.  All documentation should “match” what was coded and billed. Not only will good communication between the provider and coder enhance the documentation and coding, but also the confidence of the provider that their coder is committed to correctly coding, and billing and being reimbursed for all services rendered.

Sunday, March 30, 2014

Quick Tips for time based billing for Ob Hospitalists

Sorry I've been so long in posting... but have been zooooomingly busy. Thanks for all who have been keeping me out of mischief, and into the coding mode! .. Here's some quick tips on time-based billing that I just put out for OB hospitalists! ********************************************************************************* In an OB hospitalist practice, the usage of time based billing can be the way to go, when you have spent the majority of your time counseling your patient. In situations where this counseling and coordination of care is more than 50% of the time spent with the patient. (face to face time), usage of the “time default” may be more reflective of your care than a traditional evaluation and management code.

 When choosing to bill based upon time, CPT states that more than 50% of your visit must be spent in counseling and/or coordination of care. In addition, it requires the time to be face to face with the patient, however, it includes obtaining the pt’s HPI, chief complaint and pertinent history, the exam (if performed) and counseling that is pertinent to the problem or issue at hand.

CPT defines counseling as:
 Results of diagnostic testing
 Prognosis  Management options (eg risks, benefits, outcomes) 
 Treatment of management instructions
 Compliance with chosen management options
 Risk factor reduction
 Patient and family education

Non face to face time cannot be included as a part of your “counseling” with the patient. Non face to face time includes activities such as
 Reviewing previous records
 Reviewing previous tests
 Communicating with other professionals/written reports
 Telephone conversations with other professionals

When reporting the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face to face time) MUST BE DOCUMENTED!

 In addition, the documentation must also describe the extent and the reason for the counseling and/or activities to coordinate the care of the patient. The up-side to coding by time, is that there are no specific documentation requirements for history, exam and medical decision making. However, it is recommended that you record the pertinent information about the care clearly and concisely within the record. It is absolutely essential to record the time spent, and that it is 50% OR MORE OF THE ENTIRE VISIT TIME

 Example #1: “I spent 20 minutes of 30 minutes face to face in the L&D outpatient area discussing patients’ abnormal glucose test results and increasing blood pressure, and headache. In addition, I counseled the patient in appropriate dietary changes to be made at this early stage in pregnancy and the risk factors associated with gestational diabetes and elevated BP’s.”

 Example #2 “Total visit time with patient was 25 minutes. I spent over 50% of this time counseling the patient and spouse regarding the abnormal bleeding, ultrasound confirmation of incomplete spontaneous abortion and proposed clinical management. Patient and spouse will discuss and let me know how they wish to proceed.”

 If you are a OB hospitalist that is working in a designated OB/ED area of the hospital, usage of Emergency room codes do not allow for using “time” as an option in this place of service. When using Emergency Department E&M codes, CPT requires all three standard components of History, Exam, and Medical Decision Making to be documented and met. The bottom line for all clinical documentation is.. If it wasn’t documented it wasn’t done!

Time Threshold Chart: New Patients:
(Office POS 11, Outpatient area POS 22)
99201 10 Minutes
99202 20 Minutes
99203 30 Minutes
99204 45 Minutes
99205 60 Minutes

Established Patient: (Office POS 11 , Outpatient Area POS 22)
99212 10 Minutes
99213 15 Minutes
99214 25 Minutes
99215 40 Minutes

Hospital Observation (Admit POS 22)
99218 30 Minutes
99219 50 Minutes
99220 70 Minutes

Hospital Observation (Subseq)
 99224 15 Minutes
99225  25 Minutes
99226  35 Minutes

Hospital Inpatient (Admission POS 21)
99221 30 Minutes
99222 50 Minutes
99223 70 Minutes

Hospital Subsequent (Daily)
99231 15 Minutes
99232 25 Minutes
99233 35 Minutes