Surgical Case Coding: Lumber Spine Repair with Re-Exploration
As most medical practices are aware, not all cases are easy to navigate using the latest medical standards. The information below highlights a complicated surgical case along with the correct CPT and ICD-10 codes. Do you have a complicated surgery case need help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn— Click Here To Submit Redacted Surgery Case Study —nn
nn63709-78, 69990nG96.0, G97.41nnSURGEON: J. Smith, MD.nASSISTANT SURGEON: N. Smith, RNFAnANESTHESIOLOGIST: N/AnPREOPERATIVE DIAGNOSIS: Postoperative CSP leak.nPOSTOPERATIVE DIAGNOSIS: Postoperative CSF leak.nOPERATIVE PROCEDURE: Re-exploration of lumbar wound and repair of CSF leak.nImplications: NonenESTIMATED BLOOD LOSS: 20mLnn
HISTORY OF PRESENT ILLNESS: A 36-year-old female who underwent a revision microdiskectomy for disk reherniation at which point there was an incidental durotomy. The patient developed evidence of CSF leakage including positional headaches. She was treated with 2 blood patches and the patient seemed to improve. Subsequently, she developed a collection under her skin. This was tapped, demonstrating clear fluid consistent with CSF. Given this and the failure of blood patch for treatment of CSF leak, the patient was brought to the OR for direct repair of the CSF leak. The patient understood the risks of surgery including bleeding, infection, continued CSF leak, need for future operation, and agreed to undergo the operation.nnPROCEDURE IN DETAIL: The patient was brought to the OR, placed under general endotracheal anesthesia. She was flipped into the prone position on a Jackson table, prepped and draped in the usual fashion. The previous small incision on the left side of the back over the lumbar spine was opened with a 10 blade until clear fluid was reached. The fluid was drained, and there was a large cavity consistent with a pseudomeningocele left. The tubular retractor system was then placed down over the previous laminotomy at the site of probable CSF leak. The microscope was brought in. The durotomy and leaking CSF was easily identified, and scar tissue was carefully separated from the dura. Further laminotomy was also performed to provide room for suturing the leak. Once this was complete, a 5-0 Prolene suture was used to suture the dura back together. Valsalva after the initial closure demonstrated l area of leakage. A fat graft was then obtained from the patient’s subcutaneous fat layers, and this was sewn into the leakage area. Subsequent Valsalva maneuver did not demonstrate any leakage of CSF. Given this, it was felt that the repair was adequate to stop the CSF leak. A piece of DuraGen was then placed over the exposed dura, and DuraSeal was placed over the DuraGen. Steroids were also placed over the dura. Prior to placement of the DuraGen, the wound was thoroughly irrigated, and hemostasis was achieved with bipolar cautery and Gelfoam powder. Next, the tubular retractor system was removed. The pseudomeningocele tissue was cut away from the normal tissue using monopolar cautery and removed from the patient. Hemostasis was then achieved with bipolar cautery. Attention was then turned to closure. A watertight closure was performed in the fascial layer using 0 Vicryl sutures. Next attempts were made to close down any potential space between the fascia and fat layer using 0 Vicryl sutures. The fat layer was also reapproximated with 0 Vicryl sutures. Finally, the deep dermal layer was closed with 0 Vicryl sutures and the skin was closed with a running subcuticular Monocryl. Dermabond was placed over the wound. The patient was then flipped into the supine position, extubated, and transferred to the PACU.
UnitedHealthcare is revising the Consultation Services Policy and will no longer reimburse CPT® codes 99241-99255. This change aligns UnitedHealthcare with the Centers for Medicare and Medicaid Services (CMS). We would like to partner with care providers on older fee schedules (2009 and prior) to move to more current fee schedules.nnUnitedHealthcare will take a phased approach to implement this change as follows:nn1. Effective with dates of service of June 1, 2019, UnitedHealthcare will no longer reimburse CPT codes 99241-99255 when billed by any health care professional or medical practice with a participation agreement that includes contract rates determined on a stated year 2010 or later CMS RVU basis.nn2. Effective with dates of service of October 1, 2019, UnitedHealthcare will no longer reimburse CPT codes 99241-99255 when billed by any health care professional or medical practice.nn3. Health care professionals and medical practices should instead bill consultation services in accordance with current evaluation and management guidelines published by CMS.nn4. With respect to telehealth and telemedicine services, the Telehealth & Telemedicine Policy will continue to apply and HCPC codes G0406 – G0408, G0425 – G0427, G0508 and G0509 will be payable pursuant to that policy, the participation agreement and the member’s benefit plan.nn5. Consultation services may still be reimbursed when billed in accordance with the Preventive Care Services Coverage Determination Guideline for services such as lactation counseling.nn6. At this time, we will not be altering the Global Days Policy to apply a reduction to evaluation and management codes submitted with modifiers 25 or 57 as once announced with this Consultation Services policy change.nnCMS ceased reimbursement of consultation services CPT codes in January 2010 and increased the Relative Value Units (RVUs) for E/M codes at that time to offset this shift in its reimbursement methodology.nnFor this reason, UnitedHealthcare encourages providers who are on an older fee schedule to modernize their fee schedules to bring them into alignment with CMS’s current Relative Value Unit methodology, since the older fee schedule reimbursement does not appropriately align with current RVU structure for E/M services and many other procedure codes.nnUnitedHealthcare appreciates this change may have an impact on participating health care professionals and medical practices. So, if you have concerns or questions, or to update your fee schedule to a more current fee schedule, please reach out to your UnitedHealth Network representative.nClick 
2019 has begun a long process to eliminate redundant paperwork for providers and giving greater importance to patient interaction. One of the first changes to this multi-year program is the elimination of some home visit documentation requirements.nnE/M visits in the patient’s private residences (CPT codes 99341-99350) had, in previous years, to justify the home visit by documenting medical necessity. Effective January 1, 2019 CMS, as part of the “Final Rule”, has finalized the policy change and removed the requirement to the medical record documentation for these visits.
nnIn addition, please call your local DEA office and provide them with the details of the call.n
Rural hospitals are suffering and it is scary to those of small communities who rely on them for health care. Studies show that they are closing at a rapid rate because they just don’t have the funds. Read more below on these closings and how people are coming up with solutions for this concerning issue. nnMore than 20% of rural hospitals are at a “high risk of closing” due to wobbly finances, a Navigant analysis of publicly available data shows.nnThe study, released Wednesday, also shows that 64% of these at-risk rural hospitals are considered essential to the health and economic well-being of their communities.nnThe analysis examines the financial viability and community essentiality of more than 2,000 rural hospitals nationwide. It found that 21% of the rural hospitals are at high risk of closing based on their total operating margin, days cash on hand, and debt-to-capitalization ratio. This equates to 430 hospitals across 43 states that employ 150,000 people.nn”Our analysis shines a new light on a rural hospital crisis that must be addressed and could significantly worsen with any downturn in the economy,” study co-author David Mosley, managing director at Navigant, said in a media release.nn”Local, state, and federal politicians, as well as health system administrators, need to act,” he said.nnThe study also reviewed of the “community essentiality” of these cash-strapped rural hospitals, measuring factors such as trauma status, service to vulnerable populations, geographic isolation, and economic impact.nnThey determined that 64% or 277 of these hospitals are considered essential to their community’s health and economic well-being. In 31 states, at least half of these financially distressed rural hospitals are considered essential.nnSouthern and Midwestern states, including Mississippi, Alabama, Kansas, Georgia, and Minnesota, are projected to be impacted the most, the data shows.nnThe study blamed “multiple factors” for the ongoing crisis with rural hospitals, including low rural population growth, payer mix degradation, excess hospital capacity due to declining inpatient care, and an inability for hospitals to leverage technology due to a lack of capital.nnOne possible solution involves collaborations between rural hospitals and academic and regional health systems, that leverages the larger systems’ resources for telehealth, revenue cycle management, human capital, electronic health records, physician training, and clinical optimization.nnThe study also supports supporting legislation that advances telehealth reimbursements, such as the bipartisan Rural Emergency Acute Care Hospital (REACH) Act.nnReintroduced in 2017 by Sens. Chuck Grassley, R-Iowa, Amy Klobuchar, D-Minn., and Cory Gardner, R-Colo., the REACH Act would create a new Medicare classification under which rural hospitals would offer emergency and outpatient services but no longer have inpatient beds.n