Thursday, July 20, 2017

Communication - The bridge between providers and coders


This originally published in March of 2014... yet still has some GREAT information for all to use

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Communication - The bridge between providers and coders
March 11, 2014 (Revised and Updated  07 20 2017)

We have all heard the adage “if it wasn’t documented, it wasn’t done”.  However, in the role of the medical provider, the fast pace of the job can get in the way of the accuracy of documentation.  Unfortunately, in our current healthcare state, our practices  have to be fiscally solvent.  This is accomplished by accurate coding/billing, AND providing good patient care.  Clinical Documentation is a fundamental piece of our total job function coupled with the challenge of providing good communication to our coders for accurate coding a billing.
 

The importance of good clinical documentation cannot be underestimated.  Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care.  Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream.  If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster.  Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.
 

Documentation will always be a “necessary evil” in the role of healthcare and reimbursement.  The conversion to ICD-10 cm  (Took place on 10.01.2015) will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system.  Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.

Communication is the bridge between the provider of care, and the coder/biller.  According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or is an especially skillful writer.  As a providers and coders, think about this….. both fall into this category of expertise!  The primary function of a coder is to apply that which is written by the provider, into a numeric format; such as ICD-9cm (ICD-10cm).  However, once ICD-10cm is implemented, coders will need an excellent understanding of not only medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the written diagnoses per the documentation into the new alpha-numeric ICD-10cm format. 
ICD-10 includes many new terms, and certain codes will now require documentation to be more precise and complete to give coders the best “picture” of the care received by the patient via a numeric format.  Our challenge as good providers is to document and  communicate this new criteria more effectively so we can all share the same understanding of the words needed to continue being fiscally solvent, but to also document the clinical course of care provided. 

Unfortunately, most physician and clinical providers don’t have the "inside track" as to what criteria or “words” are needed to clearly document in ICD-9, much less for ICD-10.  Both the coder and the providers are challenged even more by the specificity needed in ICD-10.  A coder and the clinical documentation specialist are going to be looked up to as the expert.  The ‘experts’  will now be looked to help educate and inform providers how to document more clearly and to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions.  If we succeed in this endeavor, everyone benefits. 
The coding query process can help.  The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm training for the coder, clinical staff, physicians and mid-level providers will be a critical point for ICD-10cm and pcs coding success.  Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need. 

As the transition to ICD-10 marches forward, the documentation and support for ‘medical necessity’ remains.  The clinical documentation is always the first thing requested for a payment audit or review.  Not only as providers are we having to make the leap to ICD-10, but the healthcare payers are also challenged to be proficient at this new documentation system also.  We have substantial challenges for payment at this point in time.  Concern is are the payers going to be ready also, and how will they respond, if there is a question regarding documentation, payment for your services.  
Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.  

 A)  The medical record should be complete and legible
Documentation for each encounter should include:
§ Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;
§ Assessment, clinical impression or diagnosis
§ Plan of care
§ Time spent (eg face to face/counseling-coordination of care)
o   Documented time in
o   Documented time out
o   Documented total time spent (eg at bedside, on monitor(s), etc)
§ Date and Signature
§ The rationale for ordering diagnostic and other ancillary services
§ Past and present diagnoses (If pertinent to the encounter)
§ Appropriate health risk factors should be identified (if pertinent to the encounter)
§ Patient’s progress, response to and changes in treatment and/or revision of diagnosis 
B)  Avoid Ambiguous Language
Eg.. “Non-contributory” : The term “non-contributory” is  good example of ambiguous documentation.  In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed... while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported.   Be clear, concise and relevant by avoiding using the term “non-contributory”.

Another term that can be misconstrued is “abnormal” be sure to clarify, qualify, or quantify  what is “abnormal”.
C)  Clarify your diagnosis
“For a presenting problem with an established diagnosis  the documentation should reflect whether the problem is:
a)     improved, well controlled, resolving or resolved; 
b)      inadequately controlled, worsening, or failing to respond/or change as expected

“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone) 
c) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)
 

D) Ordering of Tests and Procedures
Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures

§ document ‘what’ test/procedure is being ordered.  (i.e. Fetal NST, fetal fibronectin)
§ document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement) 
E)  Omitted Information
In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however, should be used infrequently.
Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:

•Create a new entry for the additional information
•Do not annotate in the margins to add information
•Keep all entries chronological and in record sequence
•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”
•Use the actual date of the addendum, amendment or late entry
•Reference the original entry or document by indicating the date of the service
•Always sign the additional entry or document
The need for good communication and documentation brings us back to the term “wordsmith”.  Again, both the coder and the physician/provider will need to add this to their job proficiencies. Getting the conversation started is the first step.  A quick way to begin is to conduct a mini review of the current physician/provider documentation.  The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice.  If the coders’ are currently struggling with appending these “difficult” diagnoses now utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes which will be mandatory in October of 2014.  Have the coder document and analyze what they've found.  This quick analysis will help define where better communication and documentation is needed for both the coder and provider.   

Here's a quick process to help enhance communication processes for both the coder and the physician/provider of care.

  1. Ask the coder(s) and provider(s) for the top 5 mis-coded or difficult to code diagnoses
  2. Pull the operative/procedure notes that were associated with these diagnoses
  3. Cross-code the documentation with both ICD-9 and ICD-10 codes
  4. Identify areas that need to be clarified for the coder with the physician or provider
  5. Schedule a meeting (face to face)  with the coder and the provider and include
    1. The actual provider notes
    2. The ICD-9 codes (using the code -book)
    3. The ICD-10 codes (using the code-book)

Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.  
Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10. 
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 webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Friday, July 14, 2017

Medical Necessity Toolkit! Available NOW!!!+

Guess what???  My Medical Necessity Toolkit that I developed for HC-Pro is available now...  so please take advantage of some GREAT info at an extremely good price!!!  ....    Just click on the link above! ... and again. HAPPY CODING! 


Are you needing an Ed'Venture???

Hey - did you know??? Idaho State University is a CAHIIM accredited school in the State of Idaho?? AND you can get your education 100% on-line??? 
See the info below and get your ED'Venture started.... You get the opportunity to be taught by some of the most amazing faculty - These folks are GREAT!!!

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Greetings Fellow HIM Professionals:

The Idaho State University, College of Technology, Health Information Technology (HIT) program is pleased to announce that we are expanding our program to continue to meet your businesses needs and the entire health care industry’s needs. 
Our statistics show that the demand for Health Information Technicians and Medical Coders is vastly increasing each year. To compensate for this high demand, we have recently expanded our class sizes to train even more students for these health care positions. The HIT program offers both traditional seated and wholly online options, with the exception of the final hands on practicum, that prepares students to pass the Registered Health Information Technician exam once graduated.
Graduates that you hire will still have the same superior educational skills and training. The only difference in the HIT program is that it can now enroll and accept a larger number of students, and a Medical Coding Certificate option is available. Our program has proudly prepared highly qualified health information technicians and/or medical coders who have been hired by companies all over the world. We know this expansion will be a benefit to multiple health care trades including your own. 
We encourage you to take advantage of this exciting opportunity and reach out to colleagues, associates, family members, and friends who may be interested in pursuing a rewarding, profitable career in health information technology and/or medical coding. The program is particularly well suited to individuals who are already working in HIM and wish to pursue their RHIT credential. 
The program can also work with individuals who wish to retrain into the HIM field. Full and part-time student status is available. We are always available to meet with future students and help them start their successful careers!
The HIT program is now enrolling for the Fall 2017 semester, beginning in August!
For more information on the Health Information Technology program, please contact any of the following faculty:
Glenna Young, RHIA, CCS at younglen@isu.edu or 208-282-4524
Wade Lowry, RHIT at lowrwade@isu.edu or 208-282-3738
Rhonda Ward, RHIT at wardrhon@isu.edu or 208-282-2388
We are also pleased to announce the addition of full-time faculty in the Boise area, housed at the ISU Meridian Center! The faculty member can be reached at:
Mona Doan, RHIT, CCS-P at doanmona@isu.edu or 208-242-8119

Thursday, June 15, 2017

A new Webinar for me - July 2017

I will be doing another AudioEducator Webinar in July. I will be doing a webinar regarding Ultrasound Services in the physician office. We'll be discussing both Obstetric Ultrasound and Gyncologic Ultrasound. If you'd like to join me - Here's a $20.00 off "coupon code" ... and as always... I'll be Packing in a LOT of info in a short amount of time!!! You always get your $'s worth of info!
Ultrasound Services In The OB/Gyn Office
Presented By: Lori-Lynne A. Webb
Live Webinar | Date: Thu, Jul 20, 2017 | Duration: 60 minutes
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
https://www.audioeducator.com/…/ultrasound-billing-in-physi…
Become Competent in Billing Ultrasound Services in OB/Gyn Physician Offices
Get $20 Off On Registering NOW!
(Use Codé "Webb20" at Checkóut )

Thursday, April 27, 2017

The Medical Necessity Hot Button


Clearing up the confusion surrounding Medical Necessity!

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA  (originally printed through HCPro March 2017)

Understanding and determining medical necessity can be very complex for physicians, clinicians, coders, and billers.A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a patient’s family member. A third-party insurance payer may also have another completely different understanding and application of the term.

Defining medical necessity

So what is medical necessity? Coders or billers struggle to understand and sort out as the term, which leads to misinterpretation and misunderstanding of what needs to be communicated in a variety of areas.

CMS provides a specific definition under the Social Security Act:

… no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

In essence, the diagnosis drives medical necessity. Coders need to understand the diagnosis itself, as well as what services or treatment options are available to the provider.

Third-party payers add more confusion

Medical necessity can also be confusing when it comes to who is going to pay for the procedure or services. Many third-party payers have specific coverage rules regarding what they consider medically necessary or have riders and exclusions for specific procedures. Third-party payers may have a specific exclusion for procedures that they consider experimental, unproven for a specific diagnosis, or cosmetic.

One example is a surgeon using a daVinci robotic surgical device to perform a laparoscopic surgery. Upon pre-authorization for the surgery, the insurance payer states it will not pay for the surgery if the daVinci is used. The insurer’s policy includes a rider that deems the daVinci as an experimental surgical device. However, if the physician uses a traditional laparoscopic or open procedure, the third-party payer would reimburse. In this case, the insurance carrier is not stating that the surgery is not medically necessary, just that it will not reimburse for this surgery if the robotic device is used.

Even if a particular procedure or service is considered medically necessary, some payers impose limits on how many times a provider may render a specific service within a specified time frame. For Medicare and Medicaid, these limitations are known as National Coverage Determinations (NCD) and Local Coverage Determination (LCD). Private payers may simply refer to this type of limitation as a policy guideline or policy exclusion or rider.

Within these guidelines, payers may define where or when they will cover a specific service, but may limit coverage to a specific diagnosis. For example, insurance policies may have a wellness or preventive care benefit, but may only cover one such visit per year. Some payers may only reimburse for a single Prostate-Specific Antigen (PSA) test per year. The payer may require a documented screening diagnosis in coordination with the test.

If the patient underwent a PSA test January 1, 2012, for screening, his insurance may not pay for another test until 365 days (or one calendar year) have elapsed. However, if the patient undergoes a PSA blood test for screening and the test results are abnormal, the clinician may decide another PSA test is needed. The coder must submit that claim as a PSA blood test with the appropriate diagnosis for a sign, symptom, or abnormality, not as a screening.


Documenting medical necessity
Medical necessity continues to be open for interpretation by all parties involved. Many third-party payers have created lists of criteria they use to interpret medical necessity. These lists do not necessarily reflect all options, but payers include this reference in their policy guidelines.

Most providers have not developed a comprehensive listing of medically necessary qualifiers, so coders and clinicians must focus on good documentation and coding accuracy to communicate the medical necessity of services accurately to payers. If third-party payers deny reimbursement for medical services, physicians, clinicians, and coders need to rely on the formal appeal process.

Medical necessity documentation from a physician or provider should include the following:

§  Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.

§  Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.

§  Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. In other words, does the facility, office, or hospital have what the provider or clinician needs to render care?

These bullet points reflect the basics of evaluation and management (E/M) guidelines that are currently in place from CPT®: the history, exam, and medical decision making processes. Coders will have an easier time evaluating medical necessity from this aspect. Of course, a good understanding of this integration of medical necessity within the E/M guidelines makes communicating this same principle to the providers much easier. Coders should encourage providers to continually enhance their documentation to improve overall coordination between the medical record, coding accuracy, and third-party payer reimbursement.

The third-party payers employ a wide spectrum of policies defining medical necessity is and should encompass. Physicians, clinical providers, and coders should review what these payers have established within their guidelines. Someone within the physician office, hospital, or medical facility should thoroughly scrutinize these guidelines before establishing a contractual relationship with a particular third party payer. This up-front communication will help avoid claim denials in the future.

Here are some examples of what some third party payers are currently including in their medically necessary verbiage:

§  Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.

§  Treatment is necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational).

§  Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.

§  Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.

§  The disbursement of medical care and/or treatment must not be related to the patient’s or the third party payer’s monetary status or benefit.

Documentation of all medical care should accurately reflect the need for and outcome of the treatment.
Treatment or medical services deemed to be medically necessary by the provider of those services,(e.g., physician, therapist, clinician, etc.) does not imply or infer that the service(s) provided will be covered by or deemed a medically necessary service payable by a third-party insurance payer.

Medical Necessity Q&A
Q:  Could you give me some guidance on how I can instruct my MD's on avoiding vague and/or subjective clinical documentation?
A:.  Ask your providers to adequately describe his/her skilled care provided and give a clear picture of the treatment and/or “next steps” to be taken.
Do not use vague or subjective descriptions like "tolerated treatment well," "improving," "caregiver instructed on med management," or "continue with plan of care."   "patient is here for follow up"
examples of more complete and compliant statements:
1.     Patient tolerated ROM exercises with a pain level of 6/10.
2.     Patient was able to verbalize understanding and importance of checking their blood sugars prior to administering insulin.
3.     Plan for next visit: to continue education on importance of daily inspection of feet for diabetic patient, provide wound care, etc.
Q  I work in dermatology and need to know what documentation is required for excisions?  We are struggling with getting paid  
A:  The provider should include the actual "size" of the lesion/mass they are going to excise.  Then they should document the area of the excision which needs to include the lesion + any margins.  (Height, Width, Depth) and if circular/elliptical etc… and denote the "why" it was performed that way.    If you have to appeal, the problem with using strictly the sizes from a pathology report, is that tissue "shrinks" once it is excised, and the would "enlarges" once the tissue is excised. 
Q.  What is the BEST way to document our time spent… the CPT codes state a vague "time" amount but the doctors struggle with this..  
A.  Notation of Time in/Time out is always very helpful…  it is also helpful if the provider "explains"  the time.  Eg -  spent 20 minutes of our 30 minute visit discussing how to properly use their new asthma inhaler.  Or  I was requested by Dr. Doe for "standby" for a possible cesarean section during vaginal delivery.  I entered the delivery room at 0800 and departed at 0915 status post a successful vaginal delivery.


Coders must understand the complex relationships between the physician, the patient, the medical record documentation, the coder, the biller, the insurance payer, and the communication between all of these entities to successfully guide the interpretation of medical necessity.

Friday, March 31, 2017

I have a webinar for HCPRO coming up!

Are you struggling with Medical Necessity -  I have a webinar coming up on Coding and Medical Necessity...  HCPRO!!!  https://hcmarketplace.com/coding-reporting-medical-necessity

I have a LOT of great info that I'll be presenting.  I would love to have you join me!  :) 


Thursday, March 16, 2017

Webinar on 04.11.2017 Free CEU's


Good Morning!!!  Below is info for a Webinar from our friends at Navicure... 

Live Webinar: Patient Payments Check-Up™: Survey of Patient & Provider Attitudes & Behaviors
Tuesday, April 11 | 1 pm EDT / 10 am PDT

Good for 1.0 CEU (and it's free)

Click link below to get registered. - 

https://www.navicure.com/events.html

Monday, February 20, 2017

New Code 2017:  58674- Laparoscopic ablation of Uterine Fibroid Tumors
February 4, 2017

CPT has granted coders a new code for the laparoscopic ablation of uterine fibroid tumors.  As of January 1, 2017 the code is officially denoted as 58674  Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency.  The addition of this new code by CPT marks another successful transition of a code from the Category III code 0336T Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency.    Category III codes are the temporary codes set forth by CPT for emerging technology, services and procedures.  The usage of this code as a Category III code, allowed for the collection of specific data and its usage of code O336T code for ablation of fibroid tumors has allowed for CPT to create a permanent CPT code for this new technology.

The usage and transition of a Category III code to a permanent CPT code is a very good thing.  This allows for a solid RVU value allocation to the code, and insurance payers will also put this into their payment code base for standardized payment.  However, some insurance payers may still consider this to be an “experimental” code, so it is advisable to call the carrier prior to the procedure being performed to inquire about payment of this procedure with the new CPT code.

The new CPT code 58674 is primarily targeted for usage with the procedure known as Laparoscopic Radiofrequency Volumetric Thermal Ablation (RFVTA).  RFVTA is used to destroy uterine fibroids, yet preserve the uterus.  This is revolutionary for some women who still may want to pursue pregnancy, or simply to avoid major surgery such as hysterectomy, to definitively remove fibroid tumors from the uterus. 


Clinical indications and documentation

Uterine fibroids are benign, muscular tumors in a woman's uterus that can cause heavy bleeding, painful periods, pressure, and abdominal pressure, pain and distention.  According to the National Institute of Health (NIH) at least 70% of women in the US will develop fibroid tumors. Fibroids are a significant women’s health issue, and symptoms can be very mild, to very extreme.  The American Congress of Obstetricians and Gynecologists (ACOG) has stated that 39% of all hysterectomies are due to fibroid tumors and the issues related to those tumors.  Hysterectomy has been one of the more “traditional” methods for relief of fibroid uterine tumors.  The usage of a less invasive procedure that is performed laparoscopically is becoming more popular with surgeons and patients alike. 

In women who have symptoms, the most common symptoms of uterine fibroids include:
·         Heavy menstrual bleeding.
·         Menstrual periods lasting more than a week.
·         Pelvic pressure or pain.
·         Frequent urination.
·         Difficulty emptying the bladder.
·         Constipation.
·         Backache or leg pains

The ablation of these fibroid tumors via a laparoscopically delivered system of direct ablation to the uterine fibroid allows the patient to alleviate the tumor, and preserve the uterus, thereby avoiding the effects of a hysterectomy or major surgery for elimination of these tumors. 

Clinically, this procedure is considered “minimally invasive” and is performed as an outpatient procedure, and the patient can return to a normal lifestyle within 2-3 days post procedure. 

The procedure allows the surgeon to ablate targeted fibroids within the uterine cavity.  The surgeon the utilizes the laparoscopic tools to specifically targe and deliver thermal radiofrequency energy to the specific fibroid tumor with precise  tip inserted into the fibroid itself.  With this needle/tip the surgeon can then control the amount of thermal energy need to destroy the fibroid tumor. Ultrasound guidance allows the surgeon to visualize each tumor and the precise location of where the needle/tip of the tools are to be placed for successful ablation of the tumors.


RVU’s and Payment Considerations

With any new CPT code, pricing and payment is something to be considered if the physician has decided to include this into their practice.  Below is the table from CMS that outlines the National RVU’s allocated to code 58674.  This information can be accessed through the CMS link





As you can see from the above table this represents the National Payment indicators from CMS, and therefore may not represent what is the actual RVU values for your particular CMS locality.  CMS does allow for payment of this procedure, however many private insurers may still consider this an “experimental” procedure and now allow for payment of this procedure under their specific policies and contracts.

If the patient and physician have decided to pursue this method of surgical intervention, it is advisable to do a thorough pre-authorization with the patients’ insurance carrier to determine if they will pay for this new technology.  If the patient’s carries does not pay for this procedure, then you should collect up-front and/or make payment arrangements with the patient.  However, this does not preclude you, as the coder/biller from requesting a pre-authorization request for consideration of payment for this code based upon the patients’ medical necessity and the adoption of this procedure by CPT as a permanent code into the codeset, and CMS’s adoption of RVU’s.   In addition, a coder/biller can still file a claim with the patients’ insurance post procedure and submitting the operative notes and a formal request for payment.


Case Example

History:  L.W. is a 44-year-old woman (G2P2) with a 2-year history of menorrhagia and severe dysmenorrhea but no intermenstrual spotting or bleeding. We reviewed the failure of controlling her symptoms using hormonal methods, without success.

Examination: Palpation reveals that patient has an irregular, nontender uterus 8 weeks in size. Ultrasound reports for the  Transvaginal ultrasonography shows two deep, prominent, intramural fibroids. The first is 2 cm by 3 cm in size in the left lateral uterus, adjacent to the endometrial stripe. The second fibroid is 3 cm by 4 cm in the fundal region. Sonohysterography reveals no intracavitary fibroids, although the left lateral myoma has distorted the endometrial cavity.

Medical Decision Making: The patient is seeking removal of her fibroids but would like to preserve her uterus, if at all possible.  We have decided to pursue uterine-sparing fibroid treatment, performed laparoscopically instead of a hysterectomy.   Patient has signed all appropriate consents and we will contact her insurance carrier for pre-authorization and confirmation.


Operative Session/report:
Utilizing the RFVTA technique we begin with a standard 5-mm laparoscopic infraumbilical port for the camera and video laparoscope.  Placee a 12-mm port in the midline, suprapubically at the level of the uterus, and inserted the laparoscopic ultrasound probe. With the laparoscope in place I began the mapping of the uterus and outlined plan with the surgical team with the approach to destroy the fibroids.

I then inserted the handpiece containing the radiofrequency needle through the abdominal wall under laparoscopic visualization and placed the needle into the targeted fibroid using both laparoscopic and ultrasound guidance. I then accessed the first  fibroid, in the left lateral uterus and deployed the needle array to the maximum diameter necessary to begin the destruction. I then engaged the radiofrequency generator and set it for optimal destruction of the 2 x 3 cm fibroid, The fibroid was then ablated and destroyed without damage to the surrounding healthy myometrium. I then performed this same procedure upon the second fibroid in the fundal region.  This fibroid measured 3 x 4 cm with optimal destruction.  Treatment is complete, and confirmed I retracted the needle array.  I then coagulated the needle track during withdrawal of the probe, and confirmed hemostasis of all surgical areas within the uterine cavity.  All sponge and instruments counts were correct and accounted for.  The patient was then taken to recovery area in good condition.  Patient to be discharged the same day.  I will see the patient back in-office on day 3 for a postoperative check.   


Wrapping it up
As a coder, remember to code what you know, and do not assume.  If in doubt, or the documentation does not appear to be clear or is confusing, query the provider.  Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record.  Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician.  If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS. 



Lori-Lynne A. Webb, CPC, CCS-P, CCP, CDIP, 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 webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.