MHS Coding Case Studies-WEB

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From Registration to Accounts Receivable The Whole Can of Worms

2007 UBO/UBU

Conference

1

Briefing: MHS Coding Case Studies

Date: 20 March 2007

Time: 1610 - 1700


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2007 UBO/UBU Conference

From Registration to

Accounts Receivable

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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


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MHS Coding Case Studies

Data Elements on the UB-04:

UB-04, Reason for Visit, Present on Admissionrevisions 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 improvehealthcare

Continued


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POA is defined as present at the time the order for

inpatient admission occurs. Conditions that developduring 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 claimssubmissions. 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 codes45X, 516, 526

The reason for visit can have up to three ICD-9-CM

codes listed



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Case Study #1 POA

80-year-old female patient presents to the ED from thenursing 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 cellcarcinoma of the right lung. Is the small cell

carcinoma of the right lung a POA?


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Case Study #2 POA

52-year-old male is admitted for total hip replacementdue to complication from osteoarthritis. Following

surgery, he develops a pulmonary embolism. What

are the correct assignments for POA?


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Case Study #3 POA

62-year-old female is admitted from the physiciansoffice for a high fever and pneumonia. The patients

condition declines during her hospitalization and she

becomes septic according to the physician progress

notes. The physicians discharge summary listsSepsis as the primary diagnosis and Pneumonia as

a secondary diagnosis. What are the correct POA

assignments?


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Case Study #4 POA

21-year-old female is admitted to the hospital forinduction of labor at 42 weeks gestation, and

undergoes a normal delivery. What is the correct POA

assignment?


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Case Study #5 POA

25-year-old female is admitted to the hospital in activelabor. 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?


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Case Study #6 Reason for Visit

70-year-old male presents to the emergency room forshortness 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?


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25-year-old female reports to the hospital-basedurgent care clinic for headache. Following

examination, she is discharged with a sinus infection.

What is the reason for visit?


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A patient with a known history of asthma comes intothe 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?


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Case Study #9 Emergency Department (ED)

A patient is seen in the emergency department with adiagnosis of ingestion of poison. The emergency

department physician performs gastric intubation,

aspiration, and lavage, and completes a detailed

history and comprehensive exam with high-complexitydecision making

As coder for the emergency department physician, you

assign the appropriate codes


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Case Study #10 ED

A patient was seen in the ED after cutting her fingerwith 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?


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Case Study #11 ED

72-year-old Medicare patient presents to theemergency 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 edgesand dressed the wound

What are the correct code assignments?


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Case Study #12 ED

10-year-old boy was seen in the emergencydepartment 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 repairusing 6 stitches was performed. What are the correct

code assignments?


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Case Study #13 ED

Medicare patient presents to the emergencydepartment 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 beforethe fall, and the physician evaluates the problem. X-

rays and laboratory tests are normal. The physician

sutures the simple laceration


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Case Study #14 Clinic visit

A patient with an acute exacerbation of asthma is seenby 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 30minutes of initial treatment in a smoking cessation

program and a 1-week supply of nicotine gum. How is

this visit coded?


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Case Study # 15 Clinic visit

49-yr-old retired beneficiary has been evaluated over 3months (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, butnegative


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S: This established 29-year-old patient of mine comes in today

because yesterday she was playing with her cat and the cat bit herleft forearm. She states she started feeling feverish and noticedincreased redness last night and this morning. She has had no jointpain with this

O: Temp 99.2 degrees, pulse 68, resp 20, weight 142. Left armreveals 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 andgiven 1 gram of Rocephin IV today. Follow up in 24 hours. Abandage 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 tenyears ago, so she was given a tetanus booster today. She will useTylenol as needed for pain

History: Expanded problem focused

Examination: Problem focused

Medical Decision Making: Moderate


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Clinic Progress Note, Eye Examination:

Today I saw Jay, who is now 21 years old. I last sawhim 6 years ago when he had a corneal ulcer on hisright eye. This is now cleared, and he has noticed thathe cannot see well

The patient has a normal corneal anterior chamberand iris but with very slow dilating pupils. There is nopseudoexfoliation, but there are dense juvenile nuclearcataracts on both eyes; the right greater than the left. Icounseled him for cataract surgery of this right eye

first, and then the left eye, the need for postopcorrection, a 4- to 6-week recovery time, and the typeof procedure; we will see him in surgery on the lastMonday of the month


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While chasing his brother, this 13-year-old male fellthrough a sliding glass door and sustained threelacerations: 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 withsimple closure under local anesthetic

Assessment: Wounds of both knees and left hand requiresuture repair using 1% lidocaine for local anesthetic

Plan: Follow-up in 10 days for suture removal. Call office ifthere are any problems or complications


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An AD member who recently returned fromdeployment 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?


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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 writtenreport was developed


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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 leftfoot 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% Sensorcaineto the dorsum of the left foot done today

Will follow with PCP next week and return to me on

next episode of foot pain

2007 UBO/UBU C f


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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 (NewCPT code 92025 will be available in future

AHLTA upgrade)

76514 Pachymetry (no 50 modifier, bilateral code)

2007 UBO/UBU C f


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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 92070Therapeutic CL

99199 is performed as an APV



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LASIK

Post-op: At same MTF:

Diagnosis 1: V67.09 Follow-up Examination, FollowingOther 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 SurgeryDiagnosis 2: V45.69 Postsurgical State of the Eye andAdnexa

E&M: 99499

Procedure Code: S0800 or S0810 with 55 modifier forfirst f/u encounter, subsequent encounters 99024



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Case Study #23 Inpatient

Scenario: This 21-year-old gravida 1 para 1, bycesarean 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 thevaginal delivery?

B: In the above scenario, what CPT code(s) should Dr.

Dan use to report delivery of the placenta?



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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 cesareansection

Findings: Viable infant male with Apgars of 8 and 9.The infants weight is 4206g. Maternal anatomynormal, including uterus, ovaries, and tubes. She didhave significant scarring and adhesions in thesubcutaneous tissue as well as subfascially


S C C S


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Patient with menorrhagia is admitted to GYN forplanned hysterectomy. Hysterectomy was performed

the day of admission. It was determined that uterine

fibroids were the cause of menorrhagia

Plannedadmission

w/out

complication

ICD-9 E/M CPT ResponsibleClinic

Day 1 Uterine fibroids 99499 Hysterectomy GYN

Day 2 Aftercare 99499 99024 GYN

Day 3 Aftercare 99499 99024 GYN

Discharge Aftercare 99499 99024 GYN


MHS C di C St di


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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

Medical

condition

w/global

event

ICD-9 E&M CPT Responsible Clinic

Day 1 Abdominal Pain 9922199223 ~~ Family Practice

Day 2 Abdominal Pain 9923199233 ~~ Family Practice

Day 3 Appendicitis 9925199255-57 Appendectomy General Surgery

Discharge Aftercare 99499 99024 General Surgery


Q i


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Accounts ReceivableQuiz

When is POA defined?

A civilian ED encounter does not require an E&M codeunder what circumstances?

LASIK is coded using what type of code?

Does the MHS use global OB codes?

Rounds are considered what type of services?

MHS Coding Case Studies-WEB

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