Part 4 – New 2019 CPT Codes: Lymphatic, Digestive, Urinary and Nervous System
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
This is Part 4 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY 2019 and include examples to help the coder understand the new codes. There is 1 new lymphatic code, 2 new digestive system codes with 3 deletions, 3 new urinary system codes with one deletion and 7 deleted nervous system codes with 2 revisions.
Lymphatic System – Biopsy of Lymph Node
One new code was created for excision of inguinofemoral lymph nodes, 38531, Biopsy or excision of lymph node(s); open, inguinofemoral node(s (For bilateral procedure, use modifier -50). These nodes are located in the groin area and are commonly removed in conjunction with other procedures. Previously, there was not a code to identify these lymph nodes.
Digestive System – Replacement of Gastrostomy Tube
Codes 41500 and 46762 were deleted due to infrequent use. Code 43760, change of gastrostomy tube, percutaneous without guidance was deleted and replaced with two new codes:
- 43762, Replacement of gastrostomy tube, percutaneous includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract (includes contrast shot to confirm. This would not be considered guidance)
- 43763, requiring revision of gastrostomy tract
Code 43763 may require dilation and incision of tract due to stenosis or tract may require debridement. When does the tract have to be revised? If tube is left a long time, maceration around the tube occurs and there is inflammation, and the tract is then unusable.
Use 43762 for change of cecostomy tube as well. This was discussed at the AMA CPT Symposium in November.
Coders must be aware of the guidance used or not used to correctly assign replacement of gastrostomy tubes. For percutaneous replacement of gastrostomy tube under fluoroscopic guidance, use 49450. For endoscopically directed placement of gastrostomy tube see 43246.
Urinary System – Nephrostomy Tube
Code 50395 for dilation of tract for nephrostomy has been deleted. In its place, 2 new codes were created:
- 50436, Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological S&I, with post-procedure tube placement when performed. The enlargement of the existing tract to accommodate large instruments that will be used to perform other endourologic procedures.
- 50437, including new access into the renal collecting system (includes new access performed in the same session when a pre-existing tract is not present) (includes all elements of 50436)
(Do not report 50436, 50437 with 50080-81, 50384, 50430-34, 74485)
The coder must not confuse 50432, placement of percutaneous nephrostomy for drainage only with the new codes 50436 and 50437. Key words in the procedure report for 50432 are “access needle” “nephrostomy tube (catheter).” Key words for codes 50436 and 50437 are “balloon dilator” “serial dilators” “sheath.”
Finally new code 53854, Transurethral destruction of prostate tissue, by radiofrequency generated water vapor therapy was created and replaces old HCPCS code C9748. A video of water vapor therapy that usually treats BPH is located here: http://www.nxthera.com/convective-wave/
Nervous System – Various Codes Deleted
The AMA deleted codes 61332, 61480, 61610, 61612, 61642, 63615, 64508, 64550, mostly because these procedures are not done so much anymore. Two codes were revised as below (vascular family changed to territory)
▲ +61641, Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular territory
▲ +61642, Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular territory
Our final Part 5 of the series will cover miscellaneous CPT updates not covered thus far.
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.