Question

Assign CPT and ICD-10-CM codes to this Radiology Service.

LOCATION: Inpatient, Hospital
PATIENT: Jessie Gunderson
PHYSICIAN: Robert Brown, M.D.
RADIOLOGIST: Morton Monson, M.D.
EXAMINATION OF: X-Ray Chest
CLINICAL SYMPTOMS:   Acute Respiratory failure
PORTABLE CHEST, 5:00 a.m.: Comparison is made with the previous study. The cardiac silhouette is again enlarged. Since the previous study, endotracheal tube and nasogastric tube have been apparently removed. Central venous catheter is unchanged in position. There again appears to be evidence of an aortic balloon pump present, distal tip lying at the aortic arch. Again, the heart continues to be enlarged. Central vessels appear to be congested. High-volume effusions are not seen.

CONCLUSION:
1 - Persistent cardiomegaly and central vascular congestive changes. Central vessels are slightly more prominent than seen on the previous study, although I would note the patient is now extubated.
2 - Lungs appear improved when compared to previous study. Some opacities still remain in lower fields.
3 - Interim removal of nasogastric tube and endotracheal tube.

Answer 1

CPT is organized into three distinct categories. The first category, which is by far the largest of the three, contains codes for six subtypes of procedures. Much like ICD-9 and ICD-10, these procedural codes are organized into clusters, which are then subdivided into more specific ranges. For instance, codes for radiology fall in the number range of 70010 to 79999, and codes for a diagnostic ultrasound procedure fall into the range of 76506 to 76999. Within that number range, procedures have a designated code, ensuring healthcare payers record exactly which procedure a patient has undergone. For example, the codes 99213 and 99214, which you may have seen on your medical bill following a checkup, correspond to routine doctor’s visits (of simple and medium complexity, respectively). As is the case with ICD-9 or ICD-10, the goal of CPT codes is to condense as much information as possible into a uniform language. CPT codes are designed to cover all kinds of procedures and are therefore very specific. For example, the code for a 45-minute session of psychotherapy with a patient and/or family member is 90834, while the code for a 60-minute session with a patient and/or family member is 90837.

The and structure of ICD-9 coding methodology are mirrored in ICD-10. The new system, however, greatly expands the number of options that coders will have when assigning codes to describe medically necessary services. The current ICD-9 system includes 17,000 codes to describe medical conditions, external causes of morbidity, factors influencing health status, and inpatient medical procedures. ICD-10-CM contains 68,000 codes, not including the codes in ICD-10-PCS which describe procedures. This expansion in the availability of possible codes will require attentive review of available documentation in order to submit clean claims for timely reimbursement.

At first glance, the amount of detail contained in an ICD-10-CM code for an closed Bennett’s fracture may seem daunting when compared to its ICD-9-CM counterpart. A patient diagnosed with a right-sided closed Bennet’s fracture is assigned the code 815.01, Closed fracture of base of thumb (first) metacarpal. Using ICD-10-CM, the appropriate code will be S62.211A, Bennett’s fracture, right hand, initial encounter for closed fracture. A closed Bennett’s fracture of the left hand is coded S62.212A for its initial radiological examination.. The medical record should have the radiological diagnosis amply documented to substantiate code assignment under ICD-10. While translating the contents of the medical record, in this case the radiology report and requisition, into medical code is straightforward, the increased specificity of ICD-10-CM requires additional attention to detail when assigning codes. Like ICD-9, ICD-10 can be considered a language separate from, but related to the medical terminology used in patient care. Spelling is everything. Using the incorrect sixth digit in an ICD-10-CM code provides different information, as does the transposition of the fifth digit of 1 for 2 in the case of laterality. The specificity of ICD-10 coding allows third-party payers to more accurately track their beneficiaries’ ongoing treatment. Payment can conceivably be denied for a subsequent encounter to examine a patient’s left-sided Bennett’s fracture if there is no record of an initial encounter, or if the patient’s claim history indicates that the initial fracture occurred on the right versus the left reported. By adopting ICD-10-CM as the standard for reporting diagnoses for reimbursement, the intent is to reduce incidence of healthcare fraud and abuse. By specifically justifying medical necessity with highly detailed codes, a patient’s medical condition is more accurately described and monitored. This information should be readily available in the patient’s medical record. A radiology report should naturally contain the required information needed to properly assign ICD-10 codes. Whether the fracture is a Bennett’s fracture or a Rolando’s fracture is apparent to anyone who reads a radiologist’s professional diagnosis. So is which metatarsal presents the injury. Likewise, whether this is a new fracture or an older one. Any diagnosis that does not mention routine healing, delayed healing, or nonunion, will not be of clinical use to the physician who ordered the radiological exam. The components of ICD-10-CM codes are already in the radiology record. It takes trained, professional medical billers to review the record and assign codes appropriately for maximum reimbursement without denials or the need for appeals. This is true under ICD-9, and it will be even more important under ICD-10.