UCSF Clinical Enterprise Compliance Program

CECP Education SeriesWanda T. Ziemba MFA RHIT CHCO CHCC

CHC CPCAssociate Compliance Officer

& Clinical Enterprise Compliance Program

Educator

CPT CEU Coding Cruises …

Intriguing yet expensive

Let us take you on a virtual cruise…

• More cost effective!• No shuffleboard!• But … unfortunately no buffet …

And none of this Cruise

Your Cruise Itinerary for the Summer

• June 19 – Cruising Down the Alimentary Canal

• July 17 – Beauty Is Skin Deep

• August 21 – Getting to Know the Ship’s Doctor

First Port of Call:Scope Procedures

• Know where you are coming from

• Know where you are going

• Know what you are looking for

• Know how far the scope went

From Top …

Esophagus Sites

• Cervical: – Cervical begins at the lower end of pharynx

(level of 6th vertebra or lower border of cricoid cartilage) and extends to the thoracic inlet (suprasternal notch); 18 cm from incisors.

Esophagus Sites (cont.)

• Thoracic: – Upper thoracic: from thoracic inlet to level of

tracheal bifurcation; 18-23 cm.– Mid thoracic: from tracheal bifurcation midway

to gastroesophageal junction; 24-32 cm.– Lower thoracic: from midway between

tracheal bifurcation and gastroesophageal junction to GE junction, including abdominal esophagus; 32-40 cm.

Esophagus sites (cont.)

• Abdominal – Considered part of

lower thoracic esophagus; 32-40 cm.

Upper GI Endoscopy

• The Codes:– 43234 through 43259 in your CPT book

• The Exercise:– See handout, first part of procedure report

• The Prize:– You must participate to find out!– And attend all sessions

To Bottom

• The Anatomy

The Measurements

The Anatomy - DefinedParts of Colon and Rectum

Cecum (proximal right colon)--6 x 9 cm pouch covered with peritoneumAppendix--a vermiform (wormlike) diverticulum located in the lower cecumAscending colon--20-25 cm long, located behind the peritoneumHepatic flexure--lies under right lobe of liverTransverse colon--lies anterior in abdomen, attached to gastrocolic ligamentSplenic flexure--near tail of pancreas and spleenDescending colon--10-15 cm long, located behind the peritoneumSigmoid colon--loop extending distally from border of left posterior major psoas muscleRectosigmoid segment--between 10 and 15 cm from anal vergeRectum--12 cm long; upper third covered by peritoneum; no peritoneum on lower third which is also called the rectal ampulla. About 10 cm of the rectum lies below the lower edge of the peritoneum (below theperitoneal reflection), outside the peritoneal cavity.Anal canal--most distal 4-5 cm to anal verge

Proctosigmoidoscopy

• examination of the rectum and sigmoid colon

• CPT: 45300 through 45327

Sigmoidoscopy

• examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon

• CPT 45330 through 45345

Colonoscopy

• examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum

• 45355 through 45392

Scope Exercise

• It all makes sense until you see a procedure report• How will you approach the actual report?• Answer to Practice #1

– a) 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination

– b) 45391 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination

– c) 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic with/without collection of specimen (s) by brushing/washing, with/without colon decompression (separate procedure)

– d) 45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures

ICD – 10

Recent Regulatory Developments

• CMS – all systems for CID-10 compliant by 01-01-2001 and implementation mandatory by 01-01-2012– http://www.cms.hhs.gov/PerformanceBudget/

Downloads/CMSFY09CJ.pdf

• CMS ICD-10 Initiative– http://www.hhs.gov/ocio/capitalplanning/

exhibit300/FY09%20Exhibit%20300%20pages/cmsicd10initiative.html

What Does It Look Like?

• Alphanumeric codes 3-7 places, not counting the decimal or placeholders

• Tabular has 21 chapters

• Each chapter has subchapters or blocks

• Each block begins with a letter followed by two numbers

• The E and V codes are combined into the full classification system

Is It Really That Difficult?

• Higher degree of specificity

• More codes

• All Alphanumeric

• Continuing changes each year in the refinement process

Example

• UTI due to E. coli– 21 year old presents with urinary tract

infection due to Escherichia coli

• What is the code for UTI in the ICD-9-CM”

• How would you add the E.coli infection in the ICD-9-CM?

ICD-10• Infection, infected, infective (opportunistic)

urinary (tract) N39.0

• Due to E/coli: – Infection, infected, infective (opportunistic)

• Escherichia (E.) coli NEC A49.8– As cause of disease classified elsewhere B96.2– Congenital B39.8

» Sepsis P36.4– Generalized A41.51– Intestinal – see Enteritis, infectious, due to Escherichia

coli

• N39 Other disorders of urinary system– Excludes 2: hematuria NOS (R31-) – recurrent or persistent hematuria

with specified morphological lesion (N02-)

• N39.0 Urinary Tract Infection, site not specified– Use additional code (B95-B97) to identify infections

agent– Excludes 2: Candidiasis of urinary tract

(B37.4)

Neonatal urinary tract infection (P39.3)

Urinary tract infection of specified site

Exclusion Notes

• Exclusion 1: – Not coded here. Two conditions cannot occur

together such as a congenital and acquired condition

• Exclusion 2:– Not included here; two conditions may be

coded together

So What Is Your Answer?

• UTI due to E.coli

Table of Drugs & Chemicals

• One additional column– Under-dosing

• Use of place holder “x”– 1-propanol Poisoning Accidental

(unintentional) T51.3x1

Exercise 1

• 60 year old male admitted with diabetes mellitus type 2 and a stage 2 left midfoot ulcer; – Diagnosis: Ulcer of left midfoot due to type 2

diabetes mellitus

Answer to Exercise 1

• Diabetes, type 2 with ulcer– E11.621

• Diabetic Ulcer, Midfoot, fatty layer exposed– L97.422

Exercise 2

• 24 year old male patient, professional baseball player, was struck accidentally by a baseball bat while playing ball today at the Oakland Coliseum. Radiographs performed at the UCSF Medical Center show a transverse displaced fracture of the right femoral shaft. He is admitted for open reduction and internal fixation of the right femur.

• Diagnosis: Right closed displaced transverse femoral shaft fracture

Answer to Exercise 2• Closed, transverse right femoral shaft

fracture– S72.321A

• Struck by Baseball bat– W21.11xA

• Occurring at athletic field– Y92.320

• Playing group sport – baseball– Y93.0222

See You On The Next Cruise

• Skin Procedures – or – how to beautify on the high seas

• Surprise ICD – 10 Coding scenarios