Briefing:APV Coding

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

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Objectives

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

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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

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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

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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

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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

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Coding Accurately

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

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Coding Accurately

• Global periods
• Post-operative encounters
• Facility code 99199

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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 patients 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 patients
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
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Coding Example

• Dx 223.3, 593.3
• 52351 Cystourethroscopy, with ureteroscopy and/or
  pyeloscopy diagnostic
• CPT Assistant Apr 20014, May 20015, Sep 20011,
  Oct 20018 CPT Changes An Insider's View 2001
  Netter's Illustration 132 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 Assistant May 20015, Sep 20011,
  Oct 200212, Jan 200319 CPT Changes An
  Insider's View 2005
• 52235 (medium bladder tumor(s) (2.0 to 5.0 cm)
• CPT Assistant May 20015, Sep 20011,
  Oct 200212, Jan 200319 Netter's
  Illustration 132 Bladder
• 99199 Facility
• 00912 Anesthesia

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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
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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 Assistant Spring 19949, Aug 19993,
  Jan 20044, May 20053 Netter's
  Illustration 106 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 Assistant Spring 19949, Jan 19967,
  Jul 199810, Aug 19993, Jan 20044, Jan 20045,
  Jul 200415 Netter's Illustration 106 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 Assistant Spring 19949, Jul 199810,
  Feb 199911, Aug 19993, Jan 20044, Jan 20046,
  Jul 200415 Netter's Illustration 106 Mesenteric
  Relations of Intestines, 113 Mucosa and
  Musculature of Large Intestine
• 99199 facility
• No anesthesia conscious sedation included in
  colonoscopy codes

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Coding Example
History This 23 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
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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 Assistant Feb 19969, Jun 199911,
  Aug 20015, Oct 200311, Apr 200514 Netter's
  Illustration 188 Knee 29882 with meniscus repair
  (medial OR lateral)
• CPT Assistant Aug 20015, Sep 200412 Netter's
  Illustration 188 Knee
• 29877-51 Debridement/shaving of articular
  cartilage (chondroplasty)
• CPT Assistant Feb 19969, Jun 199911,
  Aug 20015, Apr 20037, Apr 200514 Netter's
  Illustration 188 Knee
• 99499 Facility
• 01382 Anesthesia