General Surgery Coding Alert

Presented by Kim Garner, CPC, CCS-P, CHCC

The following supplement to General Surgery Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Kim Garner, CPC, CCS-P, CHCC, is an independent coding and reimbursement consultant, providing audit, training and oversight of coding and reimbursement functions. She is also an approved coding instructor for the American Academy of Professional Coders Professional Medical Coding Curriculum. Kim has worked with providers in virtually all specialties, including general surgery, ob-gyn, oncology, podiatry, internal medicine and more. She has spoken at the national conference of the American Academy of Professional Coders and at numerous other programs.

Thank you Erica and I am glad to be with you all today because of some issues that we found in breast surgery and breast procedures.  I would just take a minute to tell you how I know what I know.  I started in coding and reimbursement over 20 years ago and worked in family practice, but then I went to work for a general surgery group who did quite a few breast procedures.  We had mostly general surgeons, but we did have one specific oncology surgery specialist, and of course he did mostly breast surgeries.  That was a fairly new area of general surgery many years ago and we did a lot convincing of payers and working with coding consultants, consulting with the AMA on correct coding.  So a lot of this information that I am giving you today I got from the trenches where I was actually working - coding and billing these every day and fighting with insurance companies every day.  Hopefully, I can pass this information onto you and help you in daily quest as well. 

I am wanting to go over some anatomy and terminology for the breast.  I found that sometimes we coders may get thrown in and not truly understand a lot of the anatomy and terminology of what we are doing, so I am just giving you some anatomy and terminology.  I am going to define the most common procedures that we see.  I am going to discuss some coding challenges with you.  I am also going to discuss some E&M challenges with you because, yes, surgeons may tend to think, "Okay, the surgery is my big money," but there is money that is going to be left on the table and money that is earned that the physicians rightly deserve on their E&M management services.  So I do not think that we ought to leave that behind.  I also want to discuss a question that comes up quite often and that is "when do I code breast cancer and when do I code history of breast cancer?"

I am going to give you some appeal tips and maybe some wording to help you in your pay-off.  I am going to give you some resources to fight those appeals.  I am going to give you a couple of tips on new technologies and here is my disclaimer going in: What I am going to discuss today is the correct guidelines that the American Medical Institution distributes and puts out in the CPT book.  I am going to give you some information on Medicare guidelines when they are different from the CPT guidelines.  Unfortunately, we cannot discuss all payers and I am in Alabama and that is where the bulk of my experience is.  Blue Cross of Alabama has certain guidelines.  Wherever you are, your insurance payers have guidelines, but what I am going to give you are the tools to go back to the people who wrote the codes.  When the AMA wrote the codes, these were the guidelines that they set out and so we are going to go back to those guidelines as much as possible.

Page #2 is a diagram of the breast and I felt it was quite good.  I found it on the National Institute of Health's Web site.  This might encourage you that if you have internet access, a lot of times you can find great information online about various procedures - just by doing search functions; in our world Google has become a verb, but you can Google these things and find some great information.  Of course do not take coding information that you find on the Web sites without verifying it and making sure that it is correct, but you can find great anatomy and terminology information there. 

Of course, the breast is really a fatty tissue.  It is over the muscles of the chest.  It is not a muscle itself.  It is attached to the chest wall by these ligaments.  There is a layer of fat around it that gives it a soft consistency.  I am not going to read you this terminology, you have a slide in front of you so you can just take a look at them later.  There are several that I do want to point out specific information about.

The first one is a biopsy.  In the operative reports in your office, you may hear the physician call it a biopsy.  If he takes something off and he sends it off for pathology report, in his mind, it is a biopsy; but in the coding world that is not how we define a biopsy.  The key to this is that it is a removal of a small piece of tissue from a living body needed to establish a definitive diagnosis - a small piece of tissue; it is not the whole thing.  In the coding world, the difference between a biopsy and an excision is that a biopsy is a small piece of tissue while an excision is the whole thing. 

The next term here is the cyst.  I just wanted to point that out.  You are probably familiar with those being aspirated in the office.  I wanted to point out the idea that it is an encapsulated lesion. Encapsulated is your first term on the next page, but that means that it has got a wall around it; there is a wall around it.  So you have a coding distinction you come across there where a patient has a cyst - if they just aspirate it, this means that they put a needle in and the pull the fluid out; they did not touch the cyst wall, there is a code for that: Aspiration of breast cyst; but, if they actually go in and remove the wall of the cyst, yes it is still a cyst, but at that point we consider it removing a lesion rather than just aspirating a cyst.  So sometimes that will be the distinction for you: whether or not they touch the cyst wall; whether they remove the cyst wall.

At the top of page #3, as I noted, was encapsulated.  Again, that is going to be the wall around that cyst or other structure. 

Excision, again - I know I am going to hammer this home several times for you today - but the difference between a biopsy and an excision is that a biopsy is a piece of tissue while excision is removing the whole thing.  No matter how the doctor titles the operative report, biopsy is a piece and excision is the whole thing.  Of course, fibroadenoma or fibrocystic, those are the terms you probably see in your office all day.

In situ, the second slide on page #3.  In situ, I want to talk a little bit about that.  When we are coding neoplasms, when we are coding those diagnosis codes, if you remember - if you are familiar with the neoplasm table - you have got six columns and the first three columns in that title are malignant.  The first one is primary, the second one says secondary and the third one says carcinoma in situ.  Of course, primary is the first place of malignancy where it is developed.  Secondary is a metastasis, which means it is a malignancy that has broken off and has grown somewhere else.  Carcinoma in situ is different.  It is a very small, a very well circumscribed lesion.  It has very distinct borders.  You are not going to code carcinoma in situ unless the pathology report specifically states carcinoma in situ or it may say CIS.  I have had discussions with people about the difference between primary and carcinoma in situ.  In fact, I have had a heated argument with a nurse one day because she said that all carcinoma in situ is primary and vice-versa.  She did not see the distinction.  That is something you may run across if you are a coder or a biller.  Sometimes we have different rules in coding that do not necessarily correspond with clinical guidelines and so we have to understand our coding guidelines to do our job, but you will not code this unless the physician specifically says carcinoma in situ.  In breast situations, they are very, very clear on what is carcinoma in situ because there are very different treatment options and treatment opportunities when it is carcinoma in situ.  Of course, we know what a lesion is: Basically, a change in body structure.

Neoplasm, we talked about the neoplasm table.  Palpable: you have probably seen that term and you know that distinction.  It means the physician can feel it.  He can feel the lesions that he needs to operate on.

And those are just some terminology.  Take some time and look over those and make sure that you are familiar with those.

At the second slide on page #4, let us start taking about the procedures and if you have your CPT book handy, you may want to open it to this section.  I am just going to go through the breast procedures here.

The first is puncture aspiration of the breast cyst.  Basically, you just take a needle, put in the cyst and draw the fluid out.  We talked about that a moment ago when we talked about the definition of the cyst.  Now, depending on what the physician thinks it is or if he knows what this is, he may send the fluid to pathology.  He does not always do that, so you do not have to say that you have to have a path report to do this procedure, but he may send it to pathology.  You are going to code 19000 for the first cyst.  If he does another cyst in the same breast, you are going to do 19001.  Now with 19001, you will never use modifier-51 on that.  That is an add-on code so you do not use modifier-51 on that.  Now, if it is the other breast, if the patient has a cyst in both breasts, you will code 19000 for each one because you are doing both breasts.  Now depending upon how your insurance company wants to see it, you may do 19000 with modifier-50 on one line or they may want to see two different lines, perhaps with LT and RT.  One of the points that I wanted to make with you on this was that sometimes the physician uses local anesthesia when he does this procedure and sometimes he does not.  In the surgical group that I have worked in, one of the surgeons always used a little local anesthesia when he did those.  The other surgeons said, "No. By the time, I poke them with the needle for local anesthesia, I could poke the cyst and be over it, and it feels so much better."  So it is just a difference with physicians.  If they use local anesthesia, it is not separately billable.  If you remember the CPT surgery guidelines stating that local anesthesia is never separately billable in all the procedures that you do.  Of course, local anesthesia is anything short of regional or general.  So those physicians got paid the same even though one of them used local anesthesia and one of them did not.
 
I am stepping back a bit in the CPT book on the next page talking about fine needle aspiration.  It is not in the breast section.  It is actually the first two surgery codes.  Because it is the same technique and the same code whether they do in breast, thyroid or prostate, etc. they just use a very small needle - fine needle.  It is an 18-23-gauge needle.  It is just a quick aspiration.  Now there are two different codes.  One is to say used imaging guidance that is they it under fluoroscopy, ultrasound or some other type of guidance.  10022 is if they used imaging guidance and you will bill that imaging guidance separately with a 70000-series code.  There is also a code if your physician does the aspiration and he immediately examines it to determine whether he had adequate specimen or not - there is another code that will be used and that is 88172.  Now 88172 will not generate a pathology report, but there should be some type of notation in the chart that he did this exam of the fluid. These codes, if you have been doing these as long as I have or if you have been doing these for a few years, you may remember these codes used to be lab codes.  They were 88170 and 88171 and then the AMA decided to do us all a favor and move the codes in the surgery section.  They had always been surgery codes, but because they started with the number eight, a lot of insurance companies would say, "oh, no, no, they are lab codes."  Depending on your contact, you may not have been able to have been paid for lab codes so that is just the difference in the codes that were moved to the surgery section.

Okay, the next line on that page is needle core biopsy and this is 19100.  This special biopsy needle removes the core tissue.  Now this code specifically states without imaging biopsy.  If you are going to use imaging guidance, you will not use this code at all.  We will get to the code that you will be using for that in just a moment.

Okay, incision breast biopsy - 19101.  The physician makes an incision.  He will remove a small piece of tissue.  He actually visualizes the lesion when he is removing it, but notice what this is.  It says 'biopsy'.  Remember our coding guidelines and our coding difference.  If the physician removes the entire lesion, you would not use this code.  You do it as an excision instead and that is why I think I do not see this code used very often by physicians because in most cases if they can visualize the lesion, they go ahead and remove all of it.  That is just what I see in my experience because, you know, why leave a piece of it there if they do not have to.  So I do not see this one used quite as often as I do the excisional codes.

Okay, now the codes if we do use imaging guidance.  We have 19102 for percutaneous needle core biopsy using imaging guidance and then 19103 - automated.  Now, again, if you are not using imaging guidance you are going to back up and use code 19101.  19103 is for the brand names Mammotest and Mammotome ... you may be familiar with those brand names.  The doctor may say that he did a Mammotest or a Mammotome.  This is the biopsy procedure where the patient lies face down on the table and there is actually a hole in the table for her breasts to go through the hole and then they use an automated machine.  I describe this as a 'ka-ching' kind of thing.  The needle goes in, pulls out that plug of tissue.  The patients generally are not under any anesthesia for this.  They may get a little Valium to calm them down.  Honestly they would have to calm me down before I consider that procedure!  You may have seen adds for these in the womens' magazines that show a diagram of a woman's breast with just a little Band-Aid on it and that has been advertised in that way, showing you do not have to go under anesthesia.  It does not leave a big scar.  Just a little Band-Aid type procedure.  There is also a code that can be used along with this.  It is an add-on code: 19295.  They are going to use this when they do these procedures and they want to mark the site.  It is a little metallic clip that is actually deployed through the end of the biopsy.  It is going to be used with either 19102 or 19103.  Perhaps the physician feels like that if he removes all of these calcifications, he is not going to be able to tell where they were and he wants to go back and be able to look at that slide in the future and see what develops or see what is going on.  In case there is a more definitive surgery needed, he needs to mark the spot.  So that clip is left in there.  I have been told that the patient does not feel the clip and does not know that it is there, and being that I travel a lot and go through airport security, one of my questions is will it set off security?  They tell me that no, it is deep enough in the body and there is not that much metal there so those patients are not going to have any problems going through the airport security for that. 

Page #7.  Excisional biopsy - 19120.  This is probably the most common biopsy procedure that I see.  It means the entire lesion is removed and if you look at the CPT book, the CPT description of the 19120 does not say biopsy.  It says excisional cyst, fibroadenoma, etc.  So if the entire lesion is removed, it does not matter whether you send it to pathology and it does not matter whether you get a report.  It is considered an excision.  Now notice the code description also says 'one or more lesions', but that is they do one or more lesions through the same lesion.  This would  be fairly common because when they do breast incisions they try to do them along 'Langer's lines', which are the natural stretch lines in the breast so they make the incisions through those lines.  There is less scarring and the patient is going to have lesser problems with it.  If they do one or more lesions through the same incision then code, but if they make several different incisions, you should be paid separately for those and you can identify that with the appropriate modifier.  If you have got separate incisions in the same breast, it is modifier-59.  If it is in the other breast - the contralateral breast - then you would use modifier-50 to show that it was the other breast.  Now this code can be done with males.  Now the CPT book specifically states 'male or female', but what you may run into with insurance companies or insurance payers is that they identify these in their computer systems as being strictly male or strictly female codes - and in this case they may have all the breast codes loaded in their system as female codes so they might freak out and you may need to prove to them that no, this code can be don on males.  We did remove this lesion.  We do not think as much about breast cancer in males, but it is something that is out there and that we do have to deal with.

Excisional biopsy with needle localization.  If the lesion is not palpable, the physician cannot feel it, he does not know where to cut, he does not know where to cut and he does not know which tissue to remove, in this case, this is when the breast has been prepared with a needle - they call it a wire - to localize that lesion.  Now we will talk in a few moments about actually inserting this wire.  19125 is one lesion.  19126 is each additional lesion.  Again, 19126 is an add-on code.  You would never use modifier-51 with this code.  19290 and 19291 are the two codes that you will use if surgeon places the localization needle.  Now the surgeon does not always do his own 'needle loc' as we call them; sometimes he has the radiologist do them, but I have seen it go both ways so you may want to just verify with your surgeon - does he do his own needle loc?  If he does, then you will have 19290.  You will also have a radiological guidance code and that is 76096.  We will have a slide of those towards the end of the presentation.  If the lesions are just so small and so deep that the physician cannot feel them then he will have to have them localized with a wire. 

Top slide on page #8 is just a reminder that there is a CPT code 11100 that is a skin biopsy code.  Just a reminder.  You are not going to need that for breast procedures at all.  The CPT guideline on this is that if you have a more specific code, a location-specific code then you would  use that as opposed to the general skin codes.  I had a surgeon who could not understand why he was not being paid very much for some of the biopsies he was doing.  He was coding them all as skin biopsies and he thought - and rightly so - that the skin was part of the integumentary system, but he did not realize it at that point that he should be using a breast code.  Now here is also a guideline on biopsy procedures.  If you do a biopsy and you go on to do a mastectomy, it is not to be billed separately according to the AMA guidelines.  Now what I have done before is that we had attached modifier-58 to the mastectomy.  The modifier-58 is staged or related procedure, and one of the distinctions of that is for therapy following a diagnosis.  Well, that made sense to us because the biopsy is a diagnostic procedure and the mastectomy is a therapy and we were being paid for it.  But what I like to remind folks is that just because you got paid that does not mean that you get to keep the money.  This is not correct coding per the AMA and I can direct you to that AMA guidance if you have any further questions on that, but you should not be paid and you should not code for a biopsy in the same session with a mastectomy if you are dealing with the same breast.  Now if you are talking about the contralateral breast, you do a biopsy in one breast and then you do a mastectomy on the other, then yes, of course you can be paid for those and you will have to use appropriate modifiers.  If you are doing it on the same lesion and the same breast, then you should not be coding that separately.

At the bottom of page #8 is a diagram that I found online again to show you - and for me, it really give me a good picture of what the different types of biopsy procedures were.  The first one is a fine needle aspiration, 10021 and 10022.  Basically you can see that they use a very small needle, they draw some fluid out and they basically drip it onto the slide.  Then it is analyzed.  Then the core needle, the vacuum and then the ABBI is just a brand name - it means advanced breast biopsy instrumentation.  It is just a brand name of the core needle biopsy.  And, then the open surgical biopsy.  This came from Imaginis, which is a company that makes the ABBI and I have actually give you their Web site at the end of the presentation because they have some great information on breast health and some of the different types of biopsy procedures there are.  So even if you are not using their tools, it will be a great place to get further information on breast biopsy coding.
 
At the top of page #9, we will start talking about some of the treatment procedures.  The first one that we have is 19160, partial mastectomy.  Now there were some changes in 2005 for this in the CPT book and I want to give you some details on that.  For 2005, there was some new language added to this code that said it includes terms like lumpectomy, tylectomy, quadrantectomy and segmentectomy.  Now, I for one had never had the term tylectomy, but I have been told that 'tyle' just means a lump or a lesion.  It may be a regional issue.  Maybe in your part of the country, you have heard the term tylectomy, but I just wanted you to know that is how it got put in there, it is a word for lesion or lump.  The AMA has given us new guidelines to eliminate any confusion between what is an excision and what is a mastectomy.  If you get the CPT Professional and you look at this section, you will know that there is a lot of green writing this year.  Green writing in CPT Professional means that it is new information.  Be sure to read that.  It goes into some details for you on this.  On this code, we used to say or we used to believe that you had to excise one-fourth of the breast to use this code.  That is where we were getting that quadrantectomy - a quadrant being a fourth - therefore, you had to excise at least one-fourth of the breast.  We would try to get the physicians to put that in the documentation so we would know that it is a fourth of the breast, but from what I have heard from the AMA, that was never the intention when the CPT code was written.  It was never the intention that it had to be one-fourth of the breast.  The intention was: what did you do? Was this definitive treatment to treat this patient's cancer?  So that is why they put this explanatory language in here.  It defines the type of procedures. 

Again, excision is a removal of the lesion without specific attention to adequate surgical margins.  They do not make sure that they got all of the lesion and did not leave any on the margins.  Mastectomy can still be partial or total so you can still have the 19160 - partial mastectomy - but they have to specifically state that they paid attention to the surgical margins.  This is the case where you are going to have to have some physician education.  They are going to have to start putting that in their operative report that they paid special attention to the surgical margins.  I went to the AMA CPT changes book.  Every year the AMA produces a book specifically giving information on the new codes for that year and they go into quite a bit of detail explaining why they felt that the new code was necessary and giving some examples.  They did not, however, give any wording guidance - how should word these reports.  So just let your physicians know I need to be able to read that report and tell that you paid attention to the margins.  It is not enough just to have it in the title of the operative report.  We do not code from the title of the operative report.  We code from the body of the report.  I would also expect to see it in the indication for surgery, something along the lines of: patients presenting for definitive.  That is another word that they are using, 'a definitive treatment' of this.  This is what we decided to do to remove this lesion.  That is truly what we refer to when we think of a lumpectomy.  It needs to be in the operative report, not just in the title, so the physician's intention has to be clear there.

On page #10, we have another partial mastectomy, but this is with an axillary lymphadenectomy.  This is 19162.  It is the same procedure as 19160, but you also remove the axillary lymph nodes.  You are going to use this code as well if you are doing a partial mastectomy and a sentinel node biopsy.  You will use an additional code for the lymph node injection.  Let me step back a minute and give some information and explanation of the sentinel node biopsy.  Sentinel is an old word meaning 'watchman'.  You find it in the Bible when they are talking about the watchman standing on the wall the city looking out.  If you think about lymph nodes, you know that lymph nodes are in a chain.  You can actually identify one, two, three, four, and five....  So things that flow through the lymph nodes like metastasis, dye - any thing that flows through the lymph nodes, flows in a one, two, three, four, five all the way down the pattern.  The problem for the surgeon is that when he looks at those lymph nodes he cannot see the chain.  It is not something that is easily visible.  In fact, I have had surgeons telling me that it looks like a lump of tapioca pudding with the little pearls in it - sort of gross.  So they cannot say one, two, three, four and five.  They cannot know which ones to take.  What they are trying to do here is take just the first few lymph nodes.  If they take the first few lymph nodes and those are benign then that means the cancer has not spread because if the cancer spreads it is going through the lymph nodes, one, two, three, four and five, just in order.  But because they cannot tell where one starts, then they will inject dye into this and then they will actually see the dye flow through it.  The injection code for that is 38792.  That is for injecting the dye.  Now I think that some of you might have had issues with this with insurance companies and the question came up with the AMA at their annual symposium back in November in Chicago.  In order to use this code that actually says axillary lymphadenectomy, how many lymph nodes do you have to remove?  I believe that the issue was that some insurance companies were saying that if you did not remove all the lymph nodes you could not use those codes.  The physician at the symposium - I think that was Dr. Bothe - he said that that is not true.  The code does not say complete lymphadenectomy.  The intention of removing the lymph node is to determine the future treatment.  You do not have to remove all of the lymph nodes to determine that future treatment so it is not necessary to remove all the lymph nodes to use this code.  Now he said that verbally.  I do not have anything in writing to that effect.  If that is an issue that you are fighting, I would suggest getting a clarification from the AMA in order to help you fight that issue. 

Moving on, we have simple mastectomy 19180.  That is when the breast tissue and the skin are removed, but they do not remove any lymph nodes or muscles.  A subcutaneous mastectomy is 19182.  They remove the breast tissue, but not the skin and that is sometimes the technique that they use for prophylactic mastectomy.  You have got a patient that has tested positive for the genetic markers for breast cancer and it shows him to have a prophylactic mastectomy.  Sometimes they may do this in that case.  I explain to my coding students that they make an incision under the breast, reach in, scoop out the tissue and then put in an implant in there.  There is no removing of the skin.  But sometimes in looking at operative reports, my students have trouble distinguishing this because when they see things like 'skin flaps developed', it is a little hard for them to understand.  But if you all just remember that the subcutaneous mastectomy usually has the inframammary incision - you leave the skin intact. 

The radical mastectomy, 19200 and 19220.  Of course, 19220, the urban mastectomy, is a little more radical.  They take a little more tissue then even a radical.  You rarely see this done any more.  There are just too many complications for the patient, they have too much incidence of lymphedema, the fluid swelling in their arm, and so just do not do that done very often any more.  The more common one is the modified radical, 19240.  The key to understanding the difference between this and the radical is the pectoralis major muscle.  In this case, both of them are removed, the breast tissue, the areola, the nipple, the skin and axillary lymph nodes.  With the radical mastectomy, they also remove the pectoralis major muscle.  With the modified radical, they may remove the pectoralis minor, but never the major.  Now they may remove the minor just to help them get to the lymph nodes, but that will be the distinction between those two codes for you. 

On page #12, we have the one code in here that is specifically for males.  It is mastectomy for gynecomastia, 19140.  The code specifically states 'for gynecomastia'.  In this case, they remove the fat, they remove the breast tissue, but they leave the skin and you see this done sometimes in adolescents.  You see it sometimes done in elderly men.  It is caused by those hormonal fluctuations - in teenage boys the hormones are going up and then in elderly men, the hormones are coming down, so either one of those conditions can cause this gynecomastia.  Usually, in adolescents and in teenage boys they will have hormonal testing and they will make them wait for a period of time to see if this resolves on its own.  Now as I mentioned earlier, your other mastectomy codes can be used for males as well, but you may have an issue with payers.  This code is only used when the mastectomy is done for gynecomastia.  If it is done for any other reason - such as a lesion - you are not going to use these code.  You are going to go back to one of your other mastectomy codes and, as I said earlier, you may have to fight with the insurance company over this. 

Another clarification for 2005 was that CPT codes, 19260 through 19272, are not just breast tissue.  They can be any chest wall tissue.  But there were some insurance companies that said because it is in the breast section, it has to be breast tissue.  Now notice that it states 'including the ribs' so if you do this and you remove a bit of the ribs to assist in this procedure, you are not going to code a separate musculoskeletal system code.  I think that this is one that we are not going to spend a lot of time on today because we are talking about breasts, but I wanted you to know about this change here in the clarification.  Of course, if you are going any deeper than chest wall, you will have a code in the cardiovascular section, either lungs or heart.

We got some new codes for this year and this has to be with the Mammosite radiation catheter.  Sometimes, as coders, that is something that is frustrating for us.  We will know something by a brand name, but the AMA never puts the brand name in the CPT book.  They relate it to the type of procedure.  I even went to a symposium where the physician would say, "well, this is the such-and-such procedure", but the AMA is not allowed to give brand names.  This is the Mammosite radiation catheter.  If you would like some more information on this procedure itself, I have given you their Web site at the end of the handout.  This is the case where they are doing a lumpectomy.  They are doing a 19160 or a 19162 and they decide that the patient is going to have this intracavitary radiation.  Rather than the patient going for the radiation and having the radiation sort of shot at them from the outside, the radiation is actually going to be placed inside their body.  It can be placed at the time of the lumpectomy or it can be done later as a separate procedure.  In this case, the patient's therapy is completed in five days as opposed to however many weeks with the radiation.  In this case, there is an excellent result in 88% of the patients.  One of the hazards of the radiation is that there are a lot of skin changes, almost burns, that the patient endures to treat their lesions.  In this case, because the radiation is all contained inside the body, any of those changes occur on the inside tissues and not on the outside so that is one of the benefits of this and another benefit is that it is completed in five days instead of weeks.

The next slide on that page has a code for you.  Last year, we did not have codes for these.  These are new for this year.  19296 is if you are placing it on a separate date from the partial mastectomy.  19297 is when you are placing it on the same date.  Do notice that that is an add-on code because you will be billing for the 19160, the partial mastectomy on the same day.  19298 is a different type of catheter.  It is not a balloon.  It is a tube or a button.  It is a little bit different so it is not the Mammosite catheter, but it is used for the same concept where you are treating the lesion with radiation from the inside.  Now, here is the quirk you are beginning to see in CPT.  You know most of our codes, the excisional and the biopsy, if they were done under imaging guidance, we could bill imaging guidance separately with that 70000-series code.  Not with these codes.  These codes specifically say "includes imaging guidance."  If you look through new CPT codes in general this year, you will see that that happened quite a bit.  The way the AMA is handling it these nowadays is that if they develop a CPT code and that CPT code is always done under imaging guidance, they go ahead and develop that code and price/value it based on it including the imaging guidance; so this is one where no you are not going to bill a 70000-series in addition to it.  As I said, you will see that with some other codes as well.  Those are the treatment procedures.

Now we have got some information on reconstruction procedures starting with mastopexy.  'Pexy' means to suture in place and so in this case we are suturing the breast and I jokingly tell my students that we are 'suturing them back up where they used to be'.  We usually think of this as being cosmetic, but keep in mind that this may not necessarily be considered cosmetic if the patient is undergoing reconstruction on the other breast.  Most of the times, the insurance company will cover making the unaffected breast look the same as the reconstructed breast for a better cosmetic result so you may actually see it covered. 

Then we have mammaplasty, we have reduction and we have augmentation.  19318 is the reduction.  It states "cosmetic or functional."  It is not always a cosmetic-type procedure.  There is a newer technique for breast reduction where it is a smaller scar.  The reductions used to have that anchor-shaped scar with a circle around the nipple and the areola and then a scar down the middle of the breast and then a large scar all the way under the breast.  Of course, those scars fade over time and they are not a big cosmetic issue, but they were still very large scars.  There is a newer technique with a much smaller scars and a much shorter recovery time, a couple of days as opposed to a couple of weeks.  You have got the augmentation codes, 19324 and 19325, whether or not they do a prosthetic implant.  Back to the reduction.  Just a little comment on that.  It can be considered functional and be medically necessary, and insurance companies pay for it, but you usually do have to jump through some hoops on that.  Just for example, I will share with you the Blue Cross Blue Shield of Alabama guidelines and when they cover reduction.
 
There are three conditions the patient has to have had for them to cover reduction.  The first one is intertrigo and that is a fungal infection or a fungal condition existing under the breast.  It means that the patient just keeps this fungus under the breast.  The second is history of back pain and the third is that more than 500 gm have to be removed from each breast.  500 mg is a little more than 1 pound.  So that just gives you some guidelines on that.  Other reconstruction procedures we have are reinserting a breast prosthesis.  19340 is immediate insertion; 19342 is the delayed and of course that is self explanatory.  Preparation of custom implants, that is preparing an implant so that the reconstruction breast looks just like the existing breast.  It is a more appealing cosmetic result with more symmetry there.
 
Page 15, nipple areola reconstruction, 19350.  This is usually a graft of skin or a section of the patient's existing areola that is going to be used.  The skin is usually taken from the inner thigh or from behind the ear.  Correction of inverted nipple, 19355.  They will make a couple of incisions and they will just flip the nipple into the proper position.  19357 is tissue expander, immediate or delayed .  Again when I am teaching coding and when I am doing seminars, I usually do some goofy things to help you remember.  But a tissue expander in my mind is like a Whoopie cushion.  It is a flat balloon-like implement or device that is placed through an incision and then slowly over time it is inflated.  Now notice that it says 'includes subsequent expansion' so those visits that the patient has to have it inflated cannot be billed separately.  They are included.  It is going to stretch the skin to create a breast shaped pocket for either an implant to be placed in or sometimes the tissue expander itself is an implant.  They usually stretch it slightly larger than the other breast and then they will leave the implant in, draw the saline out to make it the same size or they may have a separate procedure including a permanent implant.  After this is done, they will usually then create or tattoo a nipple in place again to give them more pleasing cosmetic result.

Page 16, Latissimus dorsi flap.  This is one that I just do not see.  In fact, I have never coded it personally.  I do not see it being done very often.  It may be a case where you have it done at your facility or where your physician does some.  What they do is that they will take the tissue from the back.  The latissimus dorsi is a large muscle across the back and they will flip it around through a tunnel under the armpit and they will creat a breast out of it, but because it is a flat, broad shaped muscle, there is usually not enough there to construct a breast so they will use an implant.  I do not see it being done very much anymore, I think because the patient is going to lose that strength in their back because of losing that muscle and they are going to have to use an implant anyway so I do not see this being done that often.  It may be a case, as hard as it is to get a CPT code in the book, it is much harder to get one out of the book.  We do have quite a few CPT codes in the book that offer things that are never, ever done anymore, but the code sits there and that may be that case with this codes.

Reconstruction with a free flap, 19364.  In this case, you  have got a flap that comes from the side of the buttocks and it take microsurgery to do this.  They have to do microvascular anastomosis to connect those tiny little blood vessels and little nerves to do this.  Again, this is one I have never seen done because of the increasing complications.  Not only do you have the breast incision, you have also now got a thigh incision or a buttock incision.  But if your physicians do this, the CPT instructions are that you are going to code the flap separately so you will have this code and you will have a code for the flap as well. 

Capsulotomy and capsulectomy.  The capsule is the scar tissue that develops around the breast implant.  We have heard some discussion about this a good bit over the past few years with silicone implants versus saline implants and complications of breast augmentation and there has been some media coverage of this in fact.  If it is a capsule or scar tissue, any time you put a foreign object in the body, it is going to reject it and sort of wall it off.  It forms this wall of scar tissue.  It can become very painful for the patient.  A capsulotomy - an  '-otomy' meaning incision - is just incision around that capsule to release that scar tissue, relieve the tightness, relieve the hardness and relieve the pain.  A capsulectomy on the other hand (an -otomy is an incision while -ectomy is to remove) is actually removing the capsule and the implant.  You would code insertion of an implant separately and you would go back to the 19340 for inserting the implant.  It is not as simple as taking the old one out and putting the new in.  They do not go into the same location.  Yes, it is in the same breast, but they will actually do dissection of a new pocket.  It may be in a different plain.  It is going to be in a slightly different location; cosmetically it may not look like a different location, but the physician has to do just as much dissection to put this new one in as he would have done to put one in if they had not removed the capsule at the same time.  So it is not an in and out type of procedure, that is why you can code both within the same session.  Now I am not saying that it is definitive that insurance companies would not give you trouble for doing both at the same session, but it is correct CPT guideline.
 
The TRAM flaps.  Probably one of the most common breast reconstruction procedures and we have the distinction between a single pedicle and a double pedicle.  You can think about a pedicle as almost like a little tube that has the blood vessels and the nerves that are still attached to the original muscle.  We are going to flip this rectus abdominis muscle.  We are going to cut it loose and we are going to flip it around, slide it up and create a breast mass out of it or a breast tissue out of it.  If we leave it attached by one pedicle, it is 19367; if we do double pedicles - that is both rectus muscles - it is 19369.  Now 19368 is called supercharging.  We actually do some microvascular anastomosis, suturing those tiny little blood vessels to sort of supercharge the blood supply to the tissue.  Now I have heard patients say that the abdominal surgery is much worse than the breast surgery as far as recovering.  The patient can be almost doubled over because they have had that abdominal muscle removed and that is a harder recovery.  In that case, they may also put a piece of mesh in to reinforce the abdominal wall.  There is not a code for putting that mesh in to reinforce the abdominal wall.  Do not try to use the hernia mesh code to capture this.  There is a code, 49568, for insertion of mesh with a hernia repair.  That will not be appropriate in this case because you are not treating hernia and that is not going to be an appropriate code to use.  There is no additional code to use in that case.  So those are the surgery codes and I want to give you some more information on mammograms because whether you do the mammograms in your office or not, you have to deal with the mammograms ordering them and some reimbursement issues on this.

On page #18, we have got the various mammogram codes.  76092 is screening.  76090 is diagnostic unilateral.  76091 is diagnostic bilateral.  So we have to think about the definition of what screening is.  By definition, a screening mammogram is a two-view study of each breast so we have some issues on what to call screening and what not to call screening.  One of the calls I have gotten actually frequently over the years is, "Kim, I need a code for a unilateral screening mammogram."  So I have to follow it up and go, ''why are you doing a screening mammogram of just one breast?"  "Oh! Well the other breast is gone to have a mastectomy."  Then it is not a screening.  A screening mammogram is done just because she is 40 years old, or just because she is that particular age.  If the patient has any indication for breast cancer or for study, it is not a screening mammogram.  A screening mammogram is just because.

We have got a couple of add-on codes now that we have digital mammography - 76082 and 76083 - and you will bill the regular 092, 090 and 091 then also the add-on codes if you have the digital enhancement done on a mammogram.  Now, the Medicare guidelines state that you can code both the screening and a diagnostic mammogram on the same day.  If the patient comes in just because it is her time, it has been 12 months since she had it, they do the mammogram and they see something.  It used to be that we would reschedule the patient for a mammogram another day or if we did it that same day we would not get paid for both, but remember that mammography is one of those unique areas that a radiologist can actually order further studies.  Just about any other area that the radiologist does studies on, he or she cannot order anything else.  He or she has to call the referring physician, explain what is going on and recommend that something has to ordered but he or she cannot order it.  But with mammograms, if a radiologist sees something on a diagnostic mammogram, he can go ahead and do an ultrasound.  Medicare states that they will pay for both.  You need modifier GG on the diagnostic.  So on the claim you would have the screening mammogram and then you have the diagnostic with modifier GG.  Of course your diagnoses codes for the screening would just be your V76 code, whichever is appropriate for you to use for that and then your diagnostic mammogram would be 794.31 or one of those appropriate codes in that series for whatever was found on the mammogram.  Medicare will pay both the same day.  I am not promising you everybody else will.

Ultrasound.  This is one I have had quite a few techs get upset with me on this because notice that it says unilateral or bilateral.  Yes, I understand it takes more work to do both breasts rather than just one breast; and as I tell folks all the time I do not write the codes I just teach them, but the codes clearly states unilateral or bilateral.  An ultrasound it going to be done if you have got a mass that is seen on mammogram, but you cannot feel it.  You want to be able to see if it is a cyst or a solid lesion and also differentiate abscesses, but again it is unilateral or bilateral so do not try to bill double just because you did both sides.

Page #19 has your codes for radiological guidance and for those procedures that we can still bill separately for imaging guidance.  Here are the code that you are going to use.  Fluoroscopy, then you have got the stereotactic, mammographic, 76098 the x-ray of surgical specimen.  That is going to be used after you have done that excision with needle localization because they will actually send the piece of the tissue with the needle or the wire still in it to radiology to x-ray and make sure that yeah, that is what we wanted to do.  You have got the right thing.  That is what we wanted you to get.  Then you get the MRI guidance and then ultrasound guidance for needle placement.

Well that covers the description of the codes and then I want to spend our remaining time talking about some coding challenges and give you some appeal information.  One of the coding challenges that I get questions about is the skin-sparing mastectomy.  It is a different mastectomy technique where we are trying to get a better cosmetic result, but there is not a code that states skin-sparing mastectomy.  Physicians tell me that it takes much longer than the traditional mastectomy so my recommendation is that you have attach modifier-22 to the mastectomy code that is appropriate.  Modifier-22 states unusual procedural service.  I have had great success using modifier-22 when I was able to prove time.  That is why I have got this one this slide to submit with the anesthesia record.  If you look at your op note you will notice that there is no time on there.  Unless the physician dictates this took me however much time, time is not on there at all, but the anesthesia record on the other hand, is the most accurate time and the only real time document of the surgery.  If you have never even seen an anesthesia record I would urge you to order one from the hospital, usually the hospital medical records will provide it for you for the surgeries your physicians participated in.  Then take a look at that and you can see on there that it is a real time, everything from vital signs to when they took the patient to the room; when they made the first incision.  Every complication is noted down there.  Everything is noted down there in real time.  That way you can prove to the insurance company something along the lines of a normal mastectomy or a regular mastectomy takes up this long; but because of the extra technique involved in the skin-sparing mastectomy it took this long and you can prove those time values.  That is true with anything that you will need to put modifier-22 on, not just this situation.  I have found that using the anesthesia record in your appeal provides you so much help because again it is the only real time documentation of what went on in that procedure.

Here is a question I get.  How do you bill a screening mammogram performed on a patient with implants?  Well, remember I have said that a screening mammogram, by definition, is a two-view film study of each breast, so both breasts.  When they do a mammogram on a patient with implants, it often takes more than two views to get an adequate view of the breast tissue because the implants may obscure some of that underlying breast tissue.  The American College of Radiology recommends that you bill it as a diagnostic mammogram; however, there are some payers that do not agree with that.  When you make the change between a screening mammogram and a diagnostic mammogram you also have some reimbursement issues with various insurance companies -  Medicare being probably the best example of that.  If the patient has a screening mammogram with Medicare they do not have to meet their deductible.  They do not owe a 20% co-insurance.  Screening mammograms are paid at 100% of the allowable by Medicare.  Diagnostic mammograms, on the other hand, are subjected to the $110 deductible and they are subject to the 20% co-insurance.  So they may try to get you to code it as a screening and this is maybe true for other insurance companies as well.  Their screenings maybe a 100%, there are others they may have to pay for.  You have to get back to what distinction it actually was and why was that ordered.  So this is the reason I have told you: ACR recommends billing that as a diagnostic, your payers might not agree so you may have an insurance company that tells you something different on billing it.

Let us talk a few minutes about evaluation and management challenges because I indicated at the onset of the conference surgeries are big money for a lot of these physicians.  In fact some physicians and some surgical specialties, not just general surgeons or breast surgeons, get so frustrated with me when I harp on E&M for them.   Because they say, "oh surgery is my big money.  I am not worried about E&M."  Well, E&M is where you are more likely to get into trouble, for one thing.  85% of all fraud investigations are brought because of E&M coding.  We need to be aware of the guidelines and we need to do it correctly.  It is also money that you could be leaving on the table.  You know yes, getting paid for a $100 visit as appose to a $1000 surgery is a little bit of money, but that $100 makes the difference in the end.
 
One of the challenges I see and the questions asked is, "is it appropriate to bill for the post-biopsy visit to discuss treatment options?"  According to the Medicare carriers manual it is separately billable.  It is going to be billable with modifier-24 and -24 states unrelated evaluation and management service during a postop period.  Now what you have to remember is what the definition of unrelated is.  Unrelated does not mean unrelated to the problem or unrelated to the diagnosis, it means unrelated to the surgery.  The way I think about it is, was the patient going to need this treatment even if they had not had the surgery?  As long as this is not for postop care and it is not caused by the surgery, it is unrelated and it is separably billable.  I have given you the Medicare carriers manual reference for that, however, the problem we are having in accessing some of that information online is that they have converted the Medicare carriers manual to what is known as the Internet Only Manual so this is not in your handout, but let me give you the reference for the Internet Only Manual section that you will need to access that.  It is Internet Only or IOM section 40.1.B.  It is the same wording.  It is just that Medicare is converting their online manuals and so they have moved things around.  It is a little harder to find.  This is your key: Treatment for the underlying condition or an added course of treatment, which is not a part of normal recovery from surgery, is billable separately.  That is what Medicare says.  Your documentation needs to indicate counseling and coordination of care to discuss treatment options.  You are going to bill it based on time spent.  I know doctors do not like to punch time clocks and they do not like to necessarily document their time, but int this case it is going to be critical to this coding.  I have seen physicians spend an hour or more with some of these patients and families discussing these treatment options and they do not have any history, they have very little exam and you do have high high-complexity decision making, but you do not have the other components to get that appropriate level of service.  So it is critical that they document time in this case.

The next slide on this page gives you a sample documentation: The patient came today, we discussed her biopsy results and treatment options.  I spent approximately 45 minutes with her in discussion.  This was exclusive of the postop wound check.  That is the key that you say that 45 minutes was separate from the postop wound check.  Remember, the postop wound check is going to be included in the surgery.  We are not trying to bill for that.  We are trying to bill for treatment for the underlying condition and you would bill that, 45 minutes qualifies for a 99215 as an established patient.  So the correct code in that situation will be 99215 with modifier 24.
 
A related E&M challenge is, how can a breast surgeon justify billing for a higher level of service?  For new patients, you have not seen them before, you have to meet all three of the key components, history, examination and decision making, at that level to code that particular level of service.  The limiting factor is going to be the examination, in my experience.  If you have got a patient presenting for a breast lesion and you suspect a breast cancer based on her mammogram or whatever, you are going to do a complete history.  Your medical decision making is going to be high based on having a diagnosis that threatens life or bodily function.  So you are going to have that but you are not necessarily going to have the high level exam.  I am never going to encourage a physician to do something that is not medically necessary in order to code at a certain level.  So it may not be necessary for the physician to examine eight organ systems or to do 18 bullet points if he is using the 1997 guidelines.  I am not going to encourage him to do that.  So how are we going to justify those higher levels of service?
 
Well, one opinion or one idea is that the 1995 guidelines allow you to do a single system exam and call it detailed or comprehensive.  Now I am not a big fan of this one because there is no guideline that tells what is a detailed or comprehensive single system exam.  We do not have anything written to tell us that.  Sometimes, you can refer to the 1997 guidelines, but in this case if you refer to the 1997 guidelines for the integumentary system, you are going to be examining skin all over the body and that is probably not going to be medically necessary in this case.  So in this case, what I think is probably going to be key again is the time.  Again, any time more than 50% of the visit is spent in counseling and coordination of care, that visit can be coded based on time.  So you have got this patient that comes in, maybe her GYN doctor has identified a breast lesion that is very suspicious.  They send her to you, the general surgeon.  You do examine her, you do take a history and you spend a total of over an hour with her but over half of that time is talking to her about breast biopsy, taking to her about her options, recommendations, that sort of things.  That visit can be coded based on time regardless of the other criteria that are met.  So that is probably the only way that you are going to justify a higher level visit in these cases unless the physician finds it medically necessary to do a more comprehensive exam.

Okay page 23, how we are going to bill for the preop visit?  Well, this is one that physicians do not like what I have to tell them a lot, it is one where I am glad they do not have any tomatoes when we see them to throw at me.  How do we bill for preop visit/  Unless the preop visit results in the decision for surgery, it is not separately billable.  It is part of the surgical fee.  It should not be billed separately.  I know that is not what they want to hear, but what you need to remember as well is that the hospital might require a history and physical, they may require that you do an H&P, that does not mean it was medically necessary to treat the patient.  Once they have had that visit to determine their need for surgery, it may not be medically necessary to have another visit before the surgery.  That visit to do the H&P is a hospital requirement, it is not necessarily something that is going to covered by insurance.

Okay let us talk a little bit about some diagnosis coding issue.  And one of them that I hear quite a bit is breast cancer versus history of breast cancer and what you have to remember is that clinical guidelines differ from coding guidelines in this area.  What you hear maybe not clinically, but you hear from family or friends or the media is that okay, once they are five years out, the are cured, they do not have breast cancer.  Well, we do not have any timelines when it comes to diagnosis coding of cancer, there is no set time defined.  But once that patient has completed therapy, whether it was surgery, radiation or chemo and they have no current signs or symptoms of the disease, they are not currently being actively treated for this disease, you do not use the cancer code any longer.  You now go to a V code and for breast cancer it is V10.3 for history of breast cancer.  Physicians though are not in that mode.  They are going to follow them for one year or two years, whatever their protocol is, that is not how we coded it though and this is something you may need to educate your physicians and to work with them on in this area and you may actually need to appeal denials.  I do not see this happening as much now as it used to.  When I was coming up in coding, I was told never use a V code, you never want to use a V code, but sometimes that is appropriate and also insurance companies are paying these more readily now.  There are quite a few V codes that are paid without any problem.  So you may not have any problem with it now, but we used to have a good bit of problems if we did a patient's three-year follow-up with V10.3, we might have some problems with denials and you may have to appeal that, and I actually have sone information on appealing that in just a few minutes.

Here are the ICD-9 CM coding guidelines.  You are not going to code conditions that were previously treated and no longer exist.  That is why we do not continue to code breast cancer when the patient has history of breast cancer.  Now here is a question that I get; "what about patients that are no Tamoxifen or Novadex?"  They would not be on that medication if they had not had breast cancer, but is it really treating the breast cancer or is it preventing a recurrence of the breast cancer?  And I actually had two oncologists who actually practiced together and they were in the same practice and they disagreed vehemently on this.  One of them said, "no she has got cancer, she has always got cancer and that is how I am going to document and that is how I am going to code it.  She is on Novadex.  She has got cancer, and that is how I am going to treat her."  The other doctor said, "no, this is preventing a recurrence.  Yes, she had cancer, but she had a mastectomy, she had tumor, she had radiation, she does not have cancer anymore, she is now history."  So this maybe a battle with your physician.

The other pet peeve I have and I do not have a slide on this for you, I will just share with you my pet tip on breast cancer coding is 174.-wherever.  I think too often we are using 174.9, which means breast cancer site unspecified.  Well, somebody knows where that was.  When the patient came in the door, we knew where that breast cancer was, it is documented somewhere.  And I think too often we fall back to the '.9' when we knew where it was.  The other thing I have seen is 174.8 use and I actually went into an oncology group several years ago to do some auditing and all of their breast cancer patients were coded 174.8 because somebody had been to a seminar and been told that it is always better to use 174.8 than 174.9.  But that is simply not true because 174.8 means something different than 174.9.  174.9 means site unspecified, 174.8 means not elsewhere classified, meaning this patient has breast cancer in a place that is not identified by one of the other codes.  How can all of these patients have this breast cancer in a funky place?  So that is just my pet peeve, somebody knows where it is and too often we default to the 174.9.  And I will warn you as ICD-10 comes into place, and that may be as soon as two years from now, you will not have these fallback unspecified codes.  You are going to have to be more specific, not just on breast cancer, but anything that has a location, you are not necessarily going to have this fallback unspecified location code.  So we need to get the physicians used to telling us where things are.

Let us talk about some appeal situations and I have referred to some already, but some of the common denials that we see when dealing with breast surgery are separate locations for excision biopsies, follow-up visit after the biopsy we talked about giving a little more detail, and then when we are using V10.3 as a diagnosis.  Let me give you some suggestions on how to appeal these.  If you are billing for two separate locations for excisional biopsies and the insurance company is denying you because the CPT description says one or more lesions.  First of all, verify that your documentation supports separate incisions, make sure you follow with modifier 59 if it was the same breast, modifier 50 if it was the other breast.  If the surgeon did not dictate it that way in the operative report, but he or she tells you that is the way it was, ask him to make an amendment to the operative report.  They can do that, there is a provision in the hospital medical records for them to make such an amendment to the medical record.  Then you can appeal it and I would reference CPT Assistant February 1996 page 10.  Let me familiarize you a little bit with the CPT Assistant.  If you have the CPT professional edition and you are going through and you notice that under some of the codes there is a little green arrow and then a notation 'CPT Assistant' with a month and year or some numbers.  What that refers to is the CPT is the bible for CPT coding where they give guidance on using the codes in the book, and this is written by the AMA and it is published monthly.  If you do not subscribe to it, maybe you have decided you do not need that, but you want to see what a particular issue say, you can order individual issues and I think it is a very minimal cost and there is the phone number I have given you for AMA where you can order individual copies.  If you want to fight this with an insurance company, the only basis you really have for this is the CPT guidance and I would order that particular issue.  And if you are looking at your CPT book you can see several notations for different issues that are involved.  So in this case it is February 1996 page 10 specifically says that code is intended to be one or more lesions through the same incision.  Separate incision, separate code.

Okay, the follow-up visit after the biopsy to discuss treatment options.  First of all your documentation needs to indicate the time spent in discussion.  If you do not have the time spent in discussion, you do not have anything to base your code choice on.  You are going to file the visit with modifier 24 and if you have to appeal it you are going to use Medicare Carrier's Manual section 4821 or as I told your earlier, they have changed it to the internet only manual and again that is 40.1.B.  It specifically states that treatment for the underlying condition is not included in the global surgical package, not related to the postoperative care of the procedure. That is a key line in that as well, not related to the postoperative care of the procedure.  Now you are saying, but Kim this is not a Medicare patient.  Well, maybe not, but this is the only guidance you have, and if they cannot show you anything else than this is what you have got to fight them on.  And I would recommend, even if you are dealing with Medicare - I believe I have spoken with some people who heir local Medicare carrier denied this - one rule I have in appealing is that I do not quit until somebody tells me 'no' three times.  I guess I am a stubborn person, but when I am appealing, there is a whole appeals process that we cannot go into today, but if you need that information e-mail me and I can send you the link to how to do Medicare appeal and followup the steps.  Once you appeal them and you have been denied and you follow the steps, the third step takes you outside of your local carrier and it takes you to the CMS regional office where you have got somebody that is not affiliated with your local carrier hearing these appeals, all of these appeal decisions have to be based on the Medicare law and that is what I am giving you, I am showing you the Medicare Law.  And so I think this is going to be key to you getting paid for those.

Okay followup visits when you are using V10.3 as the diagnosis.  What I would recommend is that you reference the American Cancer Society Recommendations for follow-up, however often the patient is recommended to follow up.  Then I would explain the coding guidelines and I will just put it to them plain and say, "had I coded this visit 174.-whatever, you would have probably paid it.  However, I am following the coding guidelines which state..." and just explain it to them in that situation.  In this case, you may also have to get the patients involved with you.  A lot of times we have insurance companies tell patients, "well if your doctor had coded it right or if your doctor had coded it differently, we would have paid it."  So I would just grab the ball and run with it and go to the patient and say, "I am following coding guidelines, this is what they say, however, your insurance company is denying this.  I cannot change my codes to meet your insurance company.  That will be fraud." Try to get the patient on your side, explaining that you are trying to do it right.  So I would think in any of these cases given the patients is involved is key.

That second slide on page 26 is just sort of a warning.  I always try to warn folks about this.  Whenever you have got new technology coming along, you have probably got a sales person from the company that developed the technology, telling you how to use it, telling you to bill for it.  Please be careful with those.  Verify that coding information.  In most cases these people do not have any coding knowledge, they do not have coders working for them.  They have just picked up a book and tried to figure out how to code it.  So they do not understand all the rules and that is their job, to sell you the equipment.  I have had several clients getting trouble with Medicare, Blue Cross or other insurance companies because they just blindly followed manufacturers' coding guidelines.  So just realize you are the one who will get in trouble.  Check those recommendations yourself and make sure they are correct.

The next slide, the next page, I have just given you the references that I used to put this together.  Again, the AMA CPT Assistant is the bible for correct coding and that is what you will use to prepare for audits, to help deal with appeals and to deal with the insurance companies on this.  So at this point operator I am ready to take some questions.

Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone.  If your question has been answered or your wish to remove yourself from the queue, please press #.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1. 

Q & A Session:

Question:  Hi Kim! How are you doing?  I do have a question regarding Mammosite catheter.  It is a situation that has actually crossed my desk already.  We have been placing Mammosites for over a year and due to the new codes, which we were very excited about, I have discovered that the codes do not address 'no partial mastectomy', like when a patient has a breast biopsy and definitively it is determined that rather than any additional surgery, the patient is going to go ahead and have a Mammosite catheter placement.  This is with only a 19120 done.  So at no point is the patient going to have a partial mastectomy and I find myself wondering whether it would be appropriate to use one of these codes, but then every time I look at them I know that that is not right, because they all are linked to the partial mastectomy.  So are we going to still have to continue to use an unlisted if the patient has a breast biopsy done followed immediately by Mammosite catheter or subsequently?

Answer:  I had not even thought of that happening.  What I think I would do Mandy is contact the AMA information services and you will have to pay to have that question answered but that maybe something they did not even think of when they designed the codes.  So I would take it up with the AMA and I think it is a minimal fee, it is about $60 or $65 to have a question such as that answered, but I know your doctors are probably going to be doing this quite a bit.

Comment:  Yeah, I have had it cross my desk twice in a month already.

Answer:  I would probably address this with the AMA and get a definitive answer from them and then perhaps then that will encourage them to either change the code next year or to take out the reference to partial mastectomy or to publish a CPT Assistant article outlining that, but right now I would say because the code specifically says partial mastectomy, I would not use this until we actually had something from the AMA.  I suspect they are going to tell you to use it, but I am hesitant to use it.

Comment:  Well, they will give it to me in writing.

Answer: Yeah and just for the other attendees, Mandy was one of my students several years ago, so we know each other.

Question:  Yes, hi.  We actually have two questions.  One is I wanted to clarify when you had mentioned you cannot charge for a biopsy and a lumpectomy, did you say you cannot charge it when it is performed at the same session?

Answer:  Yes you cannot charge both of them if they are at the same session.

Comment:  Okay, yeah, but you can if it is not the same session.

Answer:  Oh certainly.  If it is not the same session you can.  I apologize for that.

Comment:  That is okay.  The other thing is you mentioned modifier 24 used as a follow-up for an E/M for breast CA or whichever, why would you use any modifier if the sterotactic biopsy, that is more common what happens to us, they go somewhere and they get a mammotome done, they come back to our office to get results and I did not think the mammotome 19103 has any global period?

Answer:  Okay you would not need it if it did not have a global period.  That is correct, you are not going to need it without a global period.

Comment:  Okay, and the last one I promise.  Let us say a woman has a lumpectomy, then they go back within the 30 days and she needs a wider excision, what modifier would you say is the best to use, is it 58, but they are not planning on it or would it be 78 or 79?

Answer:  I would say 58 because if you look at modifier 58 in the CPT appendix A it gives you three times you will use it: one of them is planned, one of them is for therapeutic following a diagnostic, but the other is for more extensive than the original procedure and I think that is where this falls in.

Question:  Oh, hi.  I have questions again regarding the sentinel lymph nodes.  I know you discussed the 19162, but if you are using it and you are not doing that procedure if it is a 19120 and they are still doing a sentinel or 19180.  What coding do we use for the sentinel?

Answer:  It is going to be the appropriate lymph node biopsy code.

Comment:  I think it is the 38740.

Answer:  Yes, the 38740 and then the 38745 would be if it was a complete, but if it is just a sentinel it is going to be the 38740.

Question:  Do you use the 58 modifier?

Answer:  You should not need a modifier to use those two together.

Comment:  Okay, because we are being denied if we do not.

Answer:  What denial are they giving you.

Comment:  They are just not paying for the sentinel and if I send it back with the 58 to say it is staged because it came back, then they will pay.

Answer:  But you are doing them at the same session though.  If you would send me an example of that then I would like to discuss that with you because I do not think 58 is appropriate, although from what you say that is what it is taking you to get paid, but I would like to look at one of those.

Comment:  Okay.  And then just what the skin-sparing mastectomy you spoke about, what codes are you recommending to use for skin-sparing mastectomy?

Answer:  I would need to look at the op report specifically because it depends on how much tissue they are talking other than the skin.  So again, if you want to send me that I will be glad to discuss it with you.

Question:  Okay, and when the patient, last thing I am sorry, has recurrent breast cancer at the same spot that is recurrent, what coding do you use?

Answer:  I would still use the 174 whatever the location is.

Comment:  And for the same location, right?

Answer:  Right.

Question:  Well, I was listening to what she was saying about sentinel node biopsy and I have been billing those with a 38500 for about three years and we get paid for those but we do have to put a modifier 59 on them.

Answer:  She was using 58 with my question.

Comment:  Yeah and I wondered too though is she real specific about there being a separate excision to remove that sentinel node?

Answer:  And I would say probably the 38740 is just based on what the Physicians AMA had said at the symposium in November would be the more correct one to use than just the 35800.

Comment:  Yeah, I talked to my physician about that but we do not actually do a lymphadenectomy even on a real superficial level, so that is why he told us that he did not want me to bill the 38740 because it was actually tremendously more extensive than the sentinel node biopsy we were performing and since we did it through a separate excision you could say that it was a standalone procedure because it was just a little incision, you went in there, you took maybe one or two nodes and then they closed it up and they left.  So that is just something that she might want to think about, looking at her documentation when you look at that.  I have talked to several people that have said that they are using those full axillary lymphadenectomy codes even on a superficial one, but are they really doing a superficial lymphadenectomy?  I do not know, because like you said they do not give you any numbers about, well I only took out one or two nodes or I took out five, what is the line there?

Answer:  And I just know that the guidance I was giving was based on the Physicians AMA Symposium, even though you are only taking the few you are actually removing axillary lymph node and in general, you have to do what you and your physician are comfortable with because you have to whatever you and your doctors are comfortable sitting across from an auditor arguing for - that is what you have to go with.

Comment:  Yeah, okay.  Well, I wanted to be sure too because I felt like there was certainly some additional reimbursement that would have been able there if it was okay for me to legitimately bill that, but it was absolutely a comfort level for my physician that I chose to stay with the 35800.  But we had luck with the 59 modifier, but our documentation will support that.  So if she is having problems with her payer, it may just be her payer issue.

Answer:  I thought she said 58 and that is why I want to look and see if 59 was more appropriate, but either way if you will send me the documentation then we will look at it and I will be glad to talk with you about it.  Thank you Mandy.  I appreciate your help.

At this time, I have no further questions.

Okay, well thank you very much.  I appreciate all your questions and as I told Joanna, and any of the attendees, my phone number, my e-mail are on the last slide.  I will tell you I do much better with e-mail, I can answer that at 5 in the morning or 11 at night so that is easier for me.  Also I will initiate a question to the AMA on the sentinel biopsy when you are not doing a partial mastectomy and see if we can get some guidance.  I will ask the people of the Coding Institute when we get that answer to get that out to you and I will take that on and make sure that that is done.  I do appreciate your attention.  Thank you very much.

To see slides please view the PDF of this issue.