Sunday, October 2, 2016

Documentation; Diagnoses and CPT: difficult choices…….

Originally posted by as written by me...    Enjoy! 
Documentation; Diagnoses and CPT:  difficult choices…….
August 11, 2016
Coding in the outpatient realm can be a challenge.  One of the areas that coders struggle with is when there are two or more choices for similar procedures.  This creates a dilemma for the coder, as the documentation and diagnoses attached to those codes can mean a huge difference to the practice, or physician in terms of reimbursement based upon the RVU values.  In some instances, this could also mean that the choices presented in CPT may not be well represented, and the coder is then faced with the decision to go with a code that is "close", or do they choose an "unlisted" code, then have to figure out how to "price" it for payment and still get the provider/physician good reimbursement.   However, when coding with the ICD-10pcs for hospital services, it is much more clear-cut and straightforward, than those codes for physician based services that are coded from CPT.

Within the CPT code-set there are many options to code from especially when it comes to codes and procedures that can be used from the integumentary system and/or from one of the specialty organ system chapters.  Outlined below, some of the codes in the integumentary section of the CPT book , (codes 15830 – 15839) some  payers have "tagged" these codes as being not medically necessary and or cosmetic based procedures.  However, the CPT definition states nothing in relation to that assumption of that in the coding guidelines.  The codes of 15830 – 15839 the base code of 15830 states "excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilcal panniculectomy .

If you compare and contrast the CPT procedure codes of 15839 and 56620, it is clear how difficult coding choices are, if the documentation is not clear, or the physician has not included or “tied together” a straightforward diagnosis and medical necessity for the surgical procedure. 

excision excessive skin&subq tissue other area
simple vulvectomy
(Note Work RVU only)
RVU = 10.50
RVU = 08.44

The lay descriptions for codes 15830-15839 is
“The physician removes excessive skin and subcutaneous tissue (including lipectomy).  In 15830, the physician makes an incision traversing the abdomen below the belly button in a horizontal fashion. Excessive skin and subcutaneous tissue are elevated off the abdominal wall and excess tissue and fat are excised. The flaps are brought together and sutured in at least three layers. The physician may also suture the rectus abdominis muscles together in the midline to reinforce the area. Report 15832 for removal of excess skin and subcutaneous tissue on the thigh; 15833 for the leg; 15834 for the hip; 15835 for the buttock; 15836 for the arm; 15837 for the forearm or hand; 15838 for the submental fat pad (inferior to the chin); and 15839 for any other area.”

The Lay description for code 56620 is
“The physician removes part or all of the vulva to treat premalignant or malignant lesions. A simple complete vulvectomy includes removal of all of the labia majora, labia minora, and clitoris, while a simple, partial vulvectomy may include removal of part or all of the labia majora and labia minora on one side and the clitoris. The physician examines the lower genital tract and the perianal skin through a colposcope. In 56620, a wide semi-elliptical incision that contains the diseased area is made. ….”

Now to compare and contrast what happens in the real world of coding, take a look at a case study of the CPT code 15839 and CPT code 56620 vulvectomy simple;partial.   As you can see the work RVU for the code 15839 is more than the code for the 56620.

Case study comparison:
History: Patient presents with labial hypertrophy (congenital) and wishes to have a labiaplasty to even up both sides of the labia.  Patient reports tearing due to excessive length on the left side, excessive skin gets caught in clothing, and is uncomfortable when sitting for long periods of time, or becomes irritated due to her clothing.  Upon examination patient has a class 3 hypertrophy, involving the clitoral hood.   ICD-10cm diagnosis = N90.6 Hypertrophy of vulva; Hypertrophy of labia.  The physician and patient formally decide to do a labiaplasty as an outpatient procedure . The physician schedules the surgery and performs a labiaplasty.

Procedure: The risks, benefits, indications and alternatives of the procedure were discussed with the patient and informed consent was signed. The patient was then taken to the procedure room and prepped and draped in the usual sterile fashion. The labia and clitoris were then marked using the marking pen to the patient's specifications.   The perineal area was infiltrated first with the creation of a small bleb followed by infiltration of the labia majora up to the clitoris on the left side. The labia minora was then infiltrated along the lines of demarcation.  It was then clamped using Heaney clamps and the tissue excised. The clamped tissue was then cauterized using a single tip Bovie.  Excellent hemostasis was confirmed. The clitoral hood was then trimmed using scissors. The exposed tissue of clitoral hood and labia were re-approximated using 3-0 Monoderm.  Excellent hemostasis was noted. This completed the procedure. The patient tolerated the procedure and was discharged home in stable condition.  Tissue sent to Pathology – no neoplasm noted, no abnormalities noted.

In the above scenario, the coder is confused regarding which code to use, and queries to provider.   The physician responds to the query and states CPT code 15839 with dx code N90.6 is the procedure and DX that should be billed.  The physician also responded back to the coder, that he did not feel that he performed a “simple vulvectomy” because only a minimal portion of the labia was involved, as the tissue that was removed was not diseased or compromised by lesions, or other symtoms, as borne out by the pathology report.   He stated this was simply a congenital abnormality of one side was “longer” than the other. 

A few weeks later, the coder then has another labiaplasty operative report, from the same physician,  however this one is for a patient who has an ongoing issue with syringoma of the vulva (as borne out by pathology biopsy)  In this operative scenario, the coder chose to code the 56620, as this was clearly a disease process. 

Operative Report:   Patient had previous biopsy for syringoma(confirmed) D28.0 Benign neoplasm of vulva.  The labia has become enlarged and patient opted for removal as it was becoming bothersome and growing at a rapid rate. 
Findings:  three 5 mm intradermal lesions on the patients left labia and two 3mm intradermal lesions on the patients’ right laboria majora approximately 2 cm posterior to the clitoris. 
Procedure:  The patient was taken to the operating room with an IV in place.  MAC anesthesia was begun.  Pt placed in lithotomy position, prepped and draped.  Area was previously identified and marked with marking pen.  Two small elliptical incisions approximately 3cm were made on either side of the lesions.  A 15 blade was used to make an incision.  The lesions were excised from the underlying tissue .  Incisions were sewn back totether with running subcuticular stiched with 3-0 vicryl.  The patient tolerated the procedure and was discharged home in stable condition.  Tissue sent to Pathology – confirmed all lesions were denoted as syringoma. 

If the coder were coding for this procedure in ICD-10 pcs it is much more straightforward, as the code would be OUBMXZZ, where as with CPT, it is subjective between diseased tissues and normal tissues.

Another coding and billing issue that these two codes (15839 and 56620) can present, is code 15839 has a larger RVU, and could be billed as a bilateral procedure, which would have a higher financial reimbursement, than the 56620 code, which cannot be billed as a bilateral procedure and has a lower RVU value attached.  Therefore, the coder must make sure that the code choice for billing is based purely upon documentation and physician notation reflected in the operative reports, and not based upon obtaining a higher reimbursement strictly for financial purposes. 

OB/GYN is not the only specialty where this type of issue is found.  Coding for the excision of soft tissue tumors are found in the musculoskeletal section of CPT.  A soft tissue tumor,  such as a lipoma  that is in the subfascial, or subcutaneous area should be coded to the musculoskeletal section with the code range of 22900 – 22905.  Whereas,  if the lesion is a sebaceous cyst, the code choice should be from the 11400-11406 integumentary codes.  If the diagnosis is a melanoma of the skin, it might be more appropriate to use 11600-11606 for a radical resection.   If the tumors are intra-abdominal (not cutaneous or musculoskeletal) then the codes 49203 – 49205 would be more appropriate. 
Again, this is where the coder needs to truly understand the anatomy of “what” was excised, “where” it was excised, and the pathology of the tissue or masses/lesions that were excised.  The physician is responsible for documenting clearly the diagnosis, the procedure and medical necessity.  This also includes “connecting” the pathological findings back to the operative notes.  Good clinical and operative documentation is imperative for the coder/biller, the medical record documentation, the payer/insurance carrier and the patient.  The coder has the ethical and moral obligation to code what is documented without regard to financial gain.  With this in mind, the coder also needs to be aware that CPT has many surgical codes that “overlap” or are very similar.   As a coding practice standard, all coding possibilities should be reviewed carefully, then code based upon the clinical documentation.

If you are in doubt, query the provider!  Many coders rely on the old adage of “if it wasn’t documented, it wasn’t done”.   This type of coding should no longer be the rule of thumb or status quo.  If the clinical documentation denotes a service/ procedure was performed,(but poorly documented) it is well worth the time to investigate, confirm, and/or have the operative record amended by the provider, then coded and billed with accuracy.   If the insurance carriers deny your coding/billing as a “cosmetic” procedure, and the clinical documentation supports true medical necessity (not just convenience for the patient) be sure to appeal and provide the substantiating medical records to support your coding.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:  

1 comment:

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