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Briefing: APV Coding Date: 21 March 2007 Time: 1400 - 1450

Briefing: APV Coding Date: 21 March 2007 Time: 1400 - 1450 . Objectives. DoDI 6025.8 Definition of an APV Definition of an APU Documentation guidelines Coding accurately Exercises Summary Questions. DoDI 6025.8. Dated 23 September 1996

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Briefing: APV Coding Date: 21 March 2007 Time: 1400 - 1450

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  1. Briefing: APV Coding Date: 21 March 2007 Time: 1400 - 1450

  2. Objectives • DoDI 6025.8 • Definition of an APV • Definition of an APU • Documentation guidelines • Coding accurately • Exercises • Summary • Questions

  3. DoDI 6025.8 • Dated 23 September 1996 • Supersedes previous DoDI 6025.8 “Same Day Surgery” 21 July 1994 • Re-issuance and purpose • Applicability and scope • Definitions of APV and APU • Policy • Responsibilities • Procedures

  4. Definitions • APV – Ambulatory Procedure Visit • Immediate (day of), pre-procedure, and immediate post procedure care • Usually requires less than 24 hours of care in the unit • APU – Ambulatory Procedure Unit • A location within the MTF or a freestanding outpatient site • Must be equipped, staffed and designated for providing the intensive level of care required for APVs

  5. Documentation Guidelines • To ensure that medical record documentation is accurate, the following principles should be followed • The medical record should be complete and legible • The documentation of each patient encounter should include: • Reason for the encounter, relevant history, physical examination findings, and prior diagnostic test results • Assessment, clinical impression, or diagnosis • Medical plan of care • Date and legible identity of the observer —Continued—

  6. Documentation Guidelines • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred • Past and present diagnoses should be accessible to the treating and/or consulting physician • Appropriate health risk factors should be identified • The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented • The Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification codes reported on the health insurance claim form (ICD-9-CM) or billing statement should be supported by the documentation in the medical record

  7. Coding Accurately • ICD-9-CM specificity • Other conditions • Procedures • Modifiers • Surgery cancellations • Incomplete/discontinued procedures

  8. Coding Accurately • Global periods • Post-operative encounters • Facility code 99199

  9. Coding Example History: Patient is a 50 y/o man was evaluated for hematuria. A CT scan demonstrated a filling defect and possible lesion at the left ureteral pelvic junction. Description of Procedure: The patient was taken to the OR and after placement of adequate general anesthesia the patient was placed in the dorsal lithotomy position. The genitalia was prepped and draped in the usual sterile fashion. The urethra was cannulated with a cystoscope and this was passed under direct vision into the patient’s bladder. The patient was found to have both edema and probable left-sided bladder tumor extending into the posterior wall of the left bladder. Using an open-ended catheter, a left retrograde pyelogram was obtained demonstrating left ureterectasis and a left ureteral pelvic junction obstruction. A 0.035 mm guide wire was then passed under fluoroscopic guidance to the left kidney. The ureter was dilated by balloon and using the flexible ureteroscope, the patient underwent ureteroscopy. The patient was found to have a small kink in the ureter at the left ureter pelvic junction, but no lesions were noted. The ureteroscope was removed and the patient’s bladder tumor (3 cm) was resected. The periphery of the tumor was then cauterized. The patient was taken to recovery in good condition. Code assignment:

  10. Coding Example • Dx: 223.3, 593.3 • 52351Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic • CPT AssistantApr 2001:4, May 2001:5, Sep 2001:1, Oct 2001:8; CPT Changes: An Insider's View2001; Netter's Illustration132: Bladder • 52235-51 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; small bladder tumor(s) (0.5 up to 2.0 cm) • CPT AssistantMay 2001:5, Sep 2001:1, Oct 2002:12, Jan 2003:19; CPT Changes: An Insider's View2005 • 52235 (medium bladder tumor(s) (2.0 to 5.0 cm) • CPT AssistantMay 2001:5, Sep 2001:1, Oct 2002:12, Jan 2003:19; Netter's Illustration132: Bladder • 99199Facility • 00912Anesthesia

  11. Coding Example History: Colon Cancer Screening Description of Procedure: The patient was placed in a left lateral decubitus position. DRE was unremarkable. There was a 2 mm nodule in the median lobe of the prostate that felt benign. Sphincter tone was good. The colonoscope was passed into the rectum. Retroversion revealed no abnormalities. The rectal mucosa appeared normal and preparation was excellent. There was a diminutive polyp in the mid rectum. This was removed with hot biopsy forceps. The colonoscope was then advanced past the hepatic flexure where a 6 mm sessile polyp was found. This was removed by snare technique. The scope was advanced to the terminal ileum, no other abnormalities were seen. The scope was withdrawn and air removed from the colon. The patient tolerated the procedure well. Code Assignment:

  12. Coding Example • Dx: V76.51, 211.3, 211.4, 600.10 [ICD-9 Guidelines – Section IV A-1] • 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) • CPT AssistantSpring 1994:9, Aug 1999:3, Jan 2004:4, May 2005:3; Netter's Illustration106: Mesenteric Relations of Intestines, 113: Mucosa and Musculature of Large Intestine • 45385…with removal of tumor(s), polyp(s), or other lesion(s) by snare technique • CPT AssistantSpring 1994:9, Jan 1996:7, Jul 1998:10, Aug 1999:3, Jan 2004:4, Jan 2004:5, Jul 2004:15; Netter's Illustration106: Mesenteric Relations of Intestines, 113: Mucosa and Musculature of Large Intestine • 45384-51…with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery • CPT AssistantSpring 1994:9, Jul 1998:10, Feb 1999:11, Aug 1999:3, Jan 2004:4, Jan 2004:6, Jul 2004:15; Netter's Illustration106: Mesenteric Relations of Intestines, 113: Mucosa and Musculature of Large Intestine • 99199facility • No anesthesia – conscious sedation included in colonoscopy codes

  13. Coding Example History: This23 year-old male presents with a twisting knee injury consistent with medial meniscus tear of the right knee. Confirmed by MRI. Description of Procedure: The patient is brought to the OR and placed under general anesthetic. The right leg was prepped and draped sterilely then exsanguinated. The tourniquet was inflated to 350 mmHg for a total tourniquet time of 30 minutes. The trocar was placed superior medially in the knee. Anteromedial and anterolateral stab wounds were then made. The arthroscope was placed in the anterolateral portal and connected to the video arthroscope. The arthroscope was then placed through the suprapatellar pouch under the patella, where there were some grade 2 chondromalacia changes in the mid-portion of the patella. A chondroplasty was performed. The arthroscope was then placed on the medial femoral condyle into the medial compartment where some grade 2 and areas of grade 3 chondromalacia changes were noted. In addition there was a small flap tear, as well as some tearing of the posterior horn of the medial meniscus. Using a combination of basket forceps and full rays re-sector, a partial medial menisectomy was performed. In addition, chondroplasty was performed of the medial femoral condyle. The arthroscope was then placed on the intracondylar notch of the anterior cruciate ligament. It was probed, stressed and no abnormality was found. The scope was then placed in the lateral compartment where the lateral femoral condyle and lateral tibial plateau were normal. The lateral meniscus was normal. The knee was then fully irrigated, the arthroscope was removed as was the cannula that was placed superior medially in the knee. The portals were closed with 3-0 nylon sutures. The patient tolerated the procedure well. Code Assignment:

  14. Coding Example Dx: 836.0, 717.7 • 29871Arthroscopy, knee, surgical; for infection, lavage and drainage • 29881 …with meniscectomy (medial OR lateral, including any meniscal shaving) • CPT AssistantFeb 1996:9, Jun 1999:11, Aug 2001:5, Oct 2003:11, Apr 2005:14; Netter's Illustration188: Knee29882 with meniscus repair (medial OR lateral) • CPT AssistantAug 2001:5, Sep 2004:12; Netter's Illustration188: Knee • 29877-51 Debridement/shaving of articular cartilage (chondroplasty) • CPT AssistantFeb 1996:9, Jun 1999:11, Aug 2001:5, Apr 2003:7, Apr 2005:14; Netter's Illustration188: Knee • 99499Facility • 01382Anesthesia

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