Internal Medicine Coding Alert

"Sometimes a physician or group comes up with a new way of performing a procedure or service. This new procedure may work well, be more beneficial to patients and, in some circumstances, save money. But, if this service isnt clearly delineated in CPT, how do you report it?

At St. Louis University, we are doing a new procedure for which I need some help in coding, writes Brodie Poole, coding specialist in the universitys Department of Internal Medicine. The procedure is a percutaneous tracheostomy, which starts off with a bronchoscopy and eliminates the need for a surgical tracheostomy. Would you recommend the code for a bronch (31622) as well as the code for the trach (31600)? The tracheostomy description does not indicate a surgical procedure.

According to Cesar Kellar, MD, director of pulmonology for the internal medicine department at St. Louis University, the procedure differs from a surgical tracheostomy in that it can be performed at the bedside and under local anesthesia.

A percutaneous tracheostomy involves a bronchoscopic procedure to guide the percutaneous insertion of a guide wire in the trachea, which is then used to pass progressively larger dilations which opens a passage to insert a tracheostomy tube, he explains. This is all done with local anesthesia. Surgical tracheostomy involves general anesthesia, is performed in the OR, and involves an incision in the neck to open a hole in the trachea to insert the tracheostomy tube.

Tracheostomies are performed on patients in the department who are already intubated and unable to maintain an airway, he adds.

Coding Options Unclear

In cases where new procedures are being coded, the physician and coder together should read through CPT codes in the section dealing with the particular body area to determine if there is an existing code that fits that procedure.

I would read through the code 31615 and those codes for endoscopy of trachea and bronchi to see if there are any that fit, advises Cynthia Thompson, CPC, senior consultant with Gates, Moore, and Co., an accounting firm in Atlanta, GA. For example, you may want to ask the physician to read over the descriptor for 31730 (transtracheal [percutaneous] introduction of needle wire dilator/stent or indwelling tube for oxygen therapy). I would ask the physicians to carefully read the code descriptors 31600-31899 to see if any of these codes fit what they are doing. If not, then you would use the 31899 (unlisted procedure, trachea, bronchi) and send your notes and documentation of the procedure with it.

Using Unlisted Procedure Code

Janet McDiarmid, CPC, immediate past president of the American Academy of Professional Coders, believes that the procedure is indeed a new procedure and does not fit any of the existing CPT codes.

I think the code I would use is 31899 because neither of the other two options (31622 or 31600) fit that procedure unless you want to use the -52 modifier (reduced services), she says. Still, I think they should use the unlisted procedure code and send documentation. They should also lobby for a new code for this.

If a physician group chooses to report a new procedure with an unlisted procedure code, Thompson recommends not only sending accompanying documentation of the procedure but also information about the practices cost and information about the value of the procedure itself.

They need to send any articles about the procedure and its value, and where they learned the procedure as well, she says. They need to show who is doing it and why they are doing it.

The procedure may well be more amenable to the patient and more cost-effective to the payer if it involves the use of local anesthetic and a bedside procedure as opposed to general anesthesia and an operating room, Thompson believes.

But, she notes, you have to get the person processing your claim to see this, too."