on where you are. I am Scott Pellman. I am the Chairman of the OGS Coding Committee, and this is Coding for Your Urogynecologic Practice, Surgical and Office-Based Procedures. This is the second part of our two-part webinar series. The previous part on the new changes to E&M coding has been previously recorded, and if you registered for this one, you are also able to get hold of that recording and look at it if there are E&M issues that come up or questions that come up. We have speakers drawn from our Coding Committee leadership and the membership. We have Jessica Hammett from Emory University doing Eurodynamics and Office Procedure Coding, and Charles Doug Thompson from Texas Tech University, who is also the Vice Chair of the Committee, who will get to do this course next year, is also talking about Surgical Coding. We will do some coding challenges after we go through the the lectures, and then we'll open it up for coding questions and try to work through some questions and coding challenges. Jill Rathbun, who is a consultant for OGS, and Mitch Schuster, who is the former leader of this committee and probably the greatest urogynecologic coder I have ever talked to, will be available to help us with those answers, so we'll try to get you some good discussion at least. We've done the welcome and speaker introductions. In a second, I'll turn it over to Jessica and let her go through Office Procedures and Eurodynamics. We'll have Doug do the Surgical Coding, and then we'll go through our challenges. We have the appropriate legal template that you guys need to have a look at. I will let you have a look at that. The webinar is being recorded and will be available for on-demand access if you want to look at it later. We've already had a question come in about the PowerPoint slides, and everybody will be getting copies of these slides after the webinar, as well as a link to the recording, so you'll have both the narrated and the flat slide. You guys are, attendees are all muted, so we won't be able to hear you, but you have a Q&A function on your Zoom app, and if you type the question through Q&A, we can address that. That's how we'll handle our questions for the coding challenges at the end. That's the end of my slides for the introduction stuff. At this point, I'm going to turn it over to Jessica and let her talk to us about Office Procedures and Eurodynamics. All right. Oh, Colleen. Okay. Sorry, I don't have any disclosures. We'll just start with the basics of procedural coding in the office. As in everything, documentation is everything. Global payment for procedure generally includes everything pre-procedural explanation, your prep, as well as your post-procedural instructions, restrictions, precautions, what to expect recovery, as well as discussing the procedure and what happened, the plan going over the procedure, so all that is included in the procedure coding. If you bill for a procedure, then you don't also bill for an E&M code unless there's an appropriate reason to do so. There are common scenarios where you would want to bill for both the procedure and an E&M at the same encounter, so that would be if the procedure was not the reason for the visit. Now, your documentation needs to reflect the medical decision-making based on the evaluation undertaken at the visit and the options offered to the patient. Then to say, eventually, they did choose this procedure, so that would be like if a patient came and said, I have gross hematuria, you do your exam, you get your history and physical, you go, well, we're going to get a CT scan, a psychology, we need a cystoscopy as well, and the patient's like, well, you know, doc, I live four hours away, I'd really like to go ahead and get that done, then that's appropriate, you can go and do the procedure. You've done an E&M visit and you're doing a procedure. Also, if the patient comes in for a procedure and you've done the cystoscopy for gross hematuria and they say, well, you know, doc, I also have overactive bladder, can we talk about that? Then you go through your entire overactive bladder workup, you can bill for both the procedure and an E&M code. In order to qualify, it has to be a minor procedure. That means the global needs to be within zero to 10 days. It also needs to occur within the same day. The counseling and coordination of care that takes place right after a procedure is included in the procedure. Talking about the patient, what you saw in cystoscopy, what you plan to do next after that is part of the procedure, that is not an E&M code. If you have someone that you're going to bill both for procedure and an E&M code, then you want to use modifier 25. That is attached to the E&M code. Again, it needs to be a separate identifiable E&M service, same provider, same day. The best practice to do this is actually to write two notes, an E&M note and a procedure note. Let's just go over some common things that we all do in the office, pessaries. Your pessary procedure is 57160. That's the fitting and insertion of a pessary device. If you saw the patient for prolapse, did the entire workup, counseled them appropriately, and then they said, I'd like to do a pessary, can you do it today? Then you can do the pessary then and bill for both the E&M and the pessary. Again, do two notes, add the 25 onto the E&M code. A pessary has a zero-day global. Subsequent visits for pessary checks and pessary cleanings are not procedures. Those are actually billed under the E&M level. You are not going to add at that time the 57160. Now, if you refit the pessary, then you can bill. Again, if that's all you do, then you're just billing for the procedure. You're not going to bill, I refit the pessary in an E&M unless you have an appropriate reason for the E&M. If you supply the pessary, you can also charge for that. PTNS, another one we commonly do in the office. A lot of carriers will require pretty stringent documentation prior to this. We tried first and second line therapies. Here's the UA, I've got my H&P. On the sixth visit, they like to document the degree of improvement in order to continue to cover the rest of them. A lot of them also like you to do it on the 12th visit. Medicare allows you to do additional sessions every one to two months after the initial 12 sessions. Now, the other codes that I've listed here, those are actually for sacro neuromodulation. It's not appropriate to code when you're coding for PTNS. Cystoscopy with Botox. This is a special one because most carriers actually won't allow you to bill for both the procedure and an E&M code on the same day if you've done Cysto with Botox. It does have a zero day global. Again, a lot of them will have stringent criteria that you need to list that you tried first and second line therapies. Here's your PBR and your H&P. Sacro neuromodulation, there's lots of different reasons that we can do this from urge incontinence, urinary retention, fecal incontinence. Sometimes they have one and they come in and you just want to check their device. There is a code for that as well. Now, if you're going to do an office-based PNA procedure, the code is 64561. That does include imaging guidance. It's got a 10-day global, so a lot of times we can't charge for the removal or separately code for the removal because it's typically done within 10 days. Those usually don't stay in for that long. If you do it on both sides or you test both sides, then it is appropriate to code it twice. You just add the 50 modifier. Now, the fluoroscopic examination, the 760000, it cannot be added. It is already included in the 64561. Now, that is different than when you're in the operating room. In the operating room, you can add the fluoroscopic examination code. Now, when the patient comes back to see you after they've already had their sacro-neuromodulator device placed, and if you just do some integration with the device and just analyze it, then you can charge 5970. If you change programs, depending on how many programming you've changed, and I do like to record which programs I've changed, not just for billing, but also for just my own knowledge that I have tried these X programs and where the simulation was felt. If you change stereo less, there's a code. If you change stereo more, there's a code. Also, if you are spending hours in the room with the patient, there is an additional half-hour programming code that you can charge as well. However, if the device manufacturer comes in and they're the ones doing the analysis and reprogram, it's not appropriate for the provider to code. You have to do the programming yourself if you want to code for it. Now, if you saw the patient and asked them how they were doing and did a general E&M, you could still do an E&M code, but if you didn't actually program, you can't do a procedure code at that time. So, it's just some bedside procedures that I found interesting when I was researching this. IND, that actually has a 10-day flowable, so office visits for repacking and wound care checks are actually included. Now, if you have to repeat the IND or do more, then you would add a modifier 76 for that. An endometrial biopsy, if you dilate, you can also code 58120 for the dilation of the cervix. And again, with trigger point injections, it really just depends on how many vessels you've done as to what code that you'll pick. And then, of course, you can also do a pudendal nerve block. So, let's just go over a common scenario and how you would code for that. So, if you had a 57-year-old present to your office two years after you placed a midurethral sling, they have dysuria and gross hematuria, she lives about four and a half hours away by car, and you assess her complaints and decide to perform an office cystoscopy that day, how would you code for that? Well, with excellent documentation, you can code for both your procedure and for your office visit. So, the procedure wasn't the reason she came, she came because she had hematuria and dysuria, and your E&M note should reflect that workup. Now, once you've done the cystoscopy, discussing the results of that cystoscopy in the next step, that is counseling after the procedure, that's included in the procedure. So, it does meet the requirements, it has to be a minor procedure, so anything less than a global of 10 days, and the cystoscopy has global zero days. There must be clear and ideally separate documentation of the procedure, so again, we do recommend you do two notes. So, your office visit note, that would include your diagnosis of hematuria and your workup for that, the CT scan, the cystoscopy, the cytology, and counseling. You'd also want to talk about the dysuria, urine culture, UA, and then you would have a separate note talking about your cystoscopy, your procedure, your findings, and discussing the results from there. So, to code for this, you would do a 5200 for the cystoscopy, and then 99213, because she's an established patient, it wasn't that complicated, with a modifier 25 for the E&M, and again, the modifier does go in on the E&M code. So, your dynamics, so your dynamics 51726, that's just your complex cystogram. When you start adding on things like urethral pressure profile studies, avoiding pressure studies, then the codes go up to 51729. Generally, most people at least do pressure profile studies, or I'm sorry, avoiding pressure studies with this. You'd also add a code for avoiding pressure studies intra-abdominally, so this is where you're getting your intra-abdominal pressure, either vaginally, rectally, or through an ostomy. This is an add-on code, so it actually doesn't need a modifier. What an add-on code is, it's only going to be added on to another procedure. It's never going to be just done itself. You're not going to go look for somebody's intra-abdominal pressure just because you wanted to. So, it's always listed with either the 51726 through the 51729, one of those. Then, there's the complex urethral flow, that's a 51741, so if you do that, you can code, and then the EMG with the patches is 51784. They do have one for needle muscle study. I don't know that anyone does those, but there is a code for that if you do. Generally, you're going to report the CPT code with the highest work RVU first, I'm sorry, the highest RVU first. Generally, that's going to be your 51726 through the 51729, so those are your complex systograms. All other codes are going to have the 51 modifier added to them, so that's your complex urethral flow and your EMG muscle patch. Except for the 51797, that again is an add-on code, so it doesn't need a modifier. There is a zero-day global for this. You cannot build the PVR separately, and that's because it's already bundled into your procedure. Your E&M code should be billed, but only if a separate E&M service is provided. In general, that's going to be a separate problem with separate documentation. Again, add the modifier 25. You cannot build separately for your interpretation of these results or the discussion of these results, because these are included in the professional component of the urodynamics. Urodynamics can also be performed by a non-physician practitioner, but your billing requires direct supervision, so the billing provider must be present within the office. You can also do one within a global period of a procedure, and you would add modifier 79, but this is generally, it would be unrelated to the procedure that you have just done, and that typically the ICD-10 code would be different. So, just a reminder, don't double dip. Only charge for both an E&M and a procedure if you have done both, and ideally, if you have done both, it is best practice to have two separate notes and excellent documentation to back those up. All right. That is my portion. I think we're going to save questions to the end, so I will pass it on to Doug. Okay. Can everybody see the screen? Yes. Okay. Great. Well, thank you for letting me talk with, for Oggs, it is a great privilege, and as you can see, my topic is cervical coding for the urogynecologist, and let's get this going. So, the objectives tonight in my talk is to go through some of the coding scenarios that we all may see from time to time, and you are going to see a lot of codes, you are going to see a lot of RVU factors, and even some reimbursement information, and all of these, all of the reimbursement information and RVU values are taken from Oggs Coding Today, which is a very nice software program that is internet-based. I believe that Scott is going to tell us more a little bit about that later on. Tonight, even though you're going to see a bunch of codes, it's not my purpose to really teach you all about the codes that are here, because you can look those up, but I do want to stress that there are going to be a lot of modifiers. We're going to talk about global time frames, and I really want to kind of go over how to use all of these modifiers and time frames within the context of what we're talking about. So, let's move on. Here's a scenario. Many of us have seen this kind of scenario before. Let's just say this 71-year-old lady comes into the emergency room complaining of severe uterovaginal prolapse, as you can see here. She has urinary obstruction, and she's not able to hold a pessary, so you decide appropriately that she needs to have surgery. So really, you just need to decide when and what kind, and actually there are different ways to code this, depending on what you do. So, being the astute physician that you are, you decide to take her to the surgery the very next day, which is going to be hospital day number one, and you decide that you want to do a laparocopal clysis. So, what is the code for that? Well, first of all, you want to make sure that you get your diagnosis correct, and this lady has complete uterovaginal prolapse. Most of our codes are going to be in the N chapter, and so N81.3 happens to be the code for the complete uterovaginal prolapse, and you see the code for the laparocopal clysis. The RVU value is there, and the current reimbursement for 2020 is $545.31, and remember, this comes right out of coding today. So, and the global fee for this is 90 days, so we all know that we can charge that, and that's usually not very contested, but what do you do about the work done the day before, when you had to go to the emergency room, spend all this time in the ER doing her history and physical, all the documentation, and we're going to call that day zero. So, unfortunately, because a 90-day global time frame really is 91 days, because it does include the day before surgery. The day before surgery is when you do your history and physical, you do your consent forms, etc., etc. This is included, and therefore, unfortunately, you don't get any payment for this. You can charge it if you want to, but you're not gonna get any reimbursement. So you just need to understand that. So what if you have a different scenario? Let's say that you have the same patient in the hospital, you do your pre-medical work or preoperative medical workup on days one and two, and you find out that she's cleared for surgery. So you decide that she still needs a copal clysis, but you wanna add a mid urethral sling because you're a complete doctor. So the charges for that include day zero, when you see this lady in the emergency room, you are able to actually put in a claim for 99223, which is initial hospital care on the high level. And you see the RVU value and you can get over $200 for this. And you can expect to be reimbursed at $200 depending on your Medicare contract. Additionally, on day number one, you can also charge for that. And this would be subsequent hospital care. You choose to do a low hospital care for this lady because you're just rounding on her, you're waiting for all the medical clearance to happen. And you can see that you get $40 for that. Now, day two is when the global fee starts. That's really the first day of the 91 days, if you will. And therefore, that particular day, you are not going to get reimbursed for. But the other two days you should be able to get reimbursed for. So day number three, of course, is the copal clysis. We have the same code and RVU value, but we also want to do a mid urethral sling. So you see the mid urethral sling there, you see the RVU value. And believe it or not, for the short time that you're doing the mid urethral sling, the RVU value is actually higher than for the copal clysis. And you can see the reimbursement there is $764. So how do you do that? Remember that there is a multiple procedure rule whenever you do multiple procedures. So you want to take the 51 modifier, you want to use that particular modifier on whichever of the two procedures or more are less valuable. And remember that reimbursement for that procedure with the 51 modifier is going to be 50% of the normal reimbursement. So how does that actually look? Well, you can see that the copal clysis has the lower RVU value. And so you tag that particular CPT code with the 51 modifier, and you can expect to get $272.66 for that particular procedure, even though that procedure is going to take you longer in the operating room. So for a total of about a little over $1,000. And so time in the operating room spent really doesn't have any bearing on which particular charge you put first, and you need to understand that. It's always the RVU value that's going to take precedent. So keep that in mind. So now this dear lady decides that she wants to have sexual preservation. And so your patient decides that along with you, of course, with shared decision-making, that you want to do a vaginal procedure in order to preserve her sexual functioning. And therefore you decide that you want to do a vaginal hysterectomy with the removal of her ovaries, an anteroposterior and interosseal repair, and a sacrospinous ligament fixation. So you have a couple of different options here, and this is what I want to show you. Option one, you can actually code the vaginal hysterectomy and DSO separately from the anteroposterior and interosseal repair. And you can see the codes and RVU values there. And then you can use the sacrospinous ligament fixation after that. Option two, you actually have the option of coding the interosseal with the hysterectomy and DSO, and then the AMP value separately. So how does that all work out in the watch? Well, let's go through this and put in our 51 modifiers and determine exactly which one gives us the better deal. So applying the 51 modifier and the 50% reduction for option one, you can see there, you have a total of $1,068.98 and one penny. You'll notice that 58262, which is the hysterectomy, is going to be the primary procedure, and the other two get 51 modifiers. Now, I also want to stress that both of them are worth 50% of the original. It's not a 50% and then 50% of the next one. They're all just 50%. You don't have to go down to 25%. And I've heard some people make that mistake before. So option two, you get a little bit more, maybe 22 bucks more out of that particular claim. So sometimes you need to play around with the RVU values just to be able to see how you're going to benefit a little bit more from this particular surgery, and then you can decide exactly, not only what you want to do, but how you want to put in the claim. So, okay. So what if your choice of apical repair is a high utero-sacral ligament fixation? Again, the rules are just a little bit different, and we'll go over that. So in this case, you decide that you want to put the vaginal hysterectomy with the BSO separately from the AP&E repair, simply because that's the way you want to do it. Now, the high utero-sacral ligament fixation, excuse me, let me put this another way. A utero-sacral ligament fixation is generally included within the vaginal hysterectomy code unless you code it in this specific way. And you will notice that on the colpopexy, we actually use the 59 modifier. Well, the 59 modifier is a key to a very specific lock in the coding system. Now, the reason I say that is because in most normal circumstances, a colpopexy, many times we call it the McCall's coldoplasty, is not separately payable. It's rolled into the fee of the hysterectomy. However, if you do a high utero-sacral ligament repair, then we can actually put a 59 modifier on there and that will trigger payment for that particular procedure. This is actually something that you can thank Mitch Schuster for because he and the OGS, the Coding and Reimbursement Committee, were very instrumental in getting this 59 modifier recognized as a valid way to include the utero-sacral ligament fixation into this particular procedure. So that is your coding committee working for you. Now, one of the things about the 59 modifier that you need to understand is that the 59 modifier only needs to be used in cases where the 51 modifier is not appropriate to use. And in this case, it is not appropriate to use it because it will not be paid for. And so the 59 modifier is put on this because it is considered more risky. It's considered deeper in the pelvis, closer to the ureter, and therefore a little bit more risk to the patient and therefore deserves separate payment. And that's exactly what I put on the last two paragraphs there. So 59 and 51, there's a very subtle differences between them and I think it's very confusing. The two very confusing modifiers, but hopefully this clears them up just a little bit for you. So a different scenario, same patient, your patient not only has vaginal prosidentia, but also rectal prolapse. You ask your colorectal surgeon to help you and then you now choose an abdominal route to do the procedure. You do the dissection and the colorectal surgeon actually does the anterior rectal PEXI. So how do you code this? All right, so here are some codes here. First of all, you're gonna do an abdominal hysterectomy with bilateral subpendylophorectomy, and you're gonna do an abdominal sacrocopal PEXI and the anterior rectal PEXI. Now you are doing the dissection for the rectal PEXI, but your colorectal surgeon is actually going to do the support part. So is there a difference? Do you actually use the 51 modifier on this? So let's just see how this goes. With the modifiers, you are going to put a 62 modifier on the anterior rectal PEXI because that modifier signifies that two different surgeons of different specialties are doing the same procedure on this particular patient. You'll notice that the anterior rectal PEXI has the highest RVU value. So that doesn't get the 51 modifier, but the other two procedures do. And so the 62 modifier specifically means two surgeons. When two surgeons work together as a primary surgeon performing distinct parts of the procedure, each surgeon can report his or her work with modifier 62. Now the way that is paid is that for that total reimbursement the surgeons can report the same CPT code. You will add 25% to the primary code and then split that in half. And so you'll get to take on 12.5% extra for the anterior rectal PEXI, including the other two procedures. I hope that's clear. I hope that I haven't muddied the waters for you in that case. The 62 modifier is not used a great deal, but keep in mind it is only for surgeons that do the same procedure on the patient. If you're doing different procedures, then it's more appropriate to put assistant surgeon modifiers on there if you're assisting the primary surgeon. Okay, so speaking of assistant at surgery, this case turns out to be more difficult than you thought. And you asked your partner to assist. So let's talk about the assistant at surgery. Again, pretty much the same CPT codes and RBU statuses, but this time you're going to use either an 82 or a 80 modifier. The two are a little bit different, but the point is that if you are the assistant, you are going to get paid 16%, 16% of the total value of the surgery. You're spending the same amount of time in the operating room, but it's the primary surgeon that gets credit for the time before the operating room and the time after the operating room. So 16% is the value that CMS has decided to reimburse us for that. Modifier 80 is the assistant at surgery and a modifier 82 is the assistant at surgery and no resident is available. Now, the one that you use really depends on the contract for your insurance company. And some insurance companies will not take the 80 modifiers, but they will take the 82 modifier. I don't think Medicare really cares which one that you use. So hopefully that is clear and sheds a little bit of light on the time spent in the operating room and you may decide whether you think that is worth it or not. So robotics surgery. So let's just say that you are very savvy technologically and you like to use a robot for all of your surgeries and you like to preserve the cervix because you read the care study and in order to reduce the chance of erosion of mesh. Now, how are you going to code for robotic surgery? Well, one of the things that... So here are the codes here. Now, one of the things I want you to realize from this particular slide is that the robot is considered a tool and not a route. Laparoscopic is a route. Abdominal is a route. Vaginal is a route. But the robot is a tool to do a laparoscopic procedure. And so there is no increased reimbursement for the use of the robot. And in fact, with regard to a surgeon's fee, there is no special code for the robot. Now, the hospitals do have a code, but surgeons do not. So also keep in mind that the sacrocopalpexy in this particular scenario is considered the primary procedure and gets reimbursed more. So you don't want to put the 51 modifier on the sacrocopalpexy. It goes to the hysterectomy. And so you will also notice, it's not obvious from this particular slide, but the sacrocopalpexy is reimbursed at a higher rate robotically compared to abdominally. They consider that as more work in higher technology. So that may influence what you do for this lady. So just keep that in mind. So the patient has successfully gone through her surgery and now she is post-op. She comes back in two weeks with a fever. So how do you charge for that? Remember, she is in the 90-day global fee. So that two weeks is actually the time that two weeks is actually going to be covered in that 90-day global timeframe. So first of all, if she does have a wound infection, you see the code there for a wound infection, you want to code it as a CPT-99024, post-operative follow-up. Now you obviously do extra work, but this is considered a complication of the original surgery. So no extra reimbursement is given to you. However, it is important to use the 99024 because whether or not you get reimbursed for it, Medicare is tracking this particular code. And so for the future, it is very important for you to use that code. And we may talk a little bit about what that means later on in the talk. Keep in mind that if you are the assistant, it is the same code if you are covering for your partner and you see this patient. Again, you don't get any extra reimbursement. It's the same code if you did not participate in the surgery, but you are in the same group and the same specialty because you are coding under the same billing number. And so again, you're seeing that patient for free. So now what if the patient has a different diagnosis? What if this patient actually comes in with a fever and has simple pharyngitis? You check her wound. The wound doesn't have any cellulitis or abscess, but she does have a really swollen red tonsils and so you diagnose her with pharyngitis. You see the diagnoses there and you note that she is in a post-procedural state. You actually do get to bill for that separately with a 24 modifier. So the 24 modifier is an unrelated E&M service during a postoperative period by the same physician. A strep throat is clearly unrelated to the surgery. And so again, this particular modifier is a key to unlocking that door for reimbursement. So keep that in mind. You'll also notice that the 25 modifier is on the 99024. And the reason for that is that you can consider that as a separate code to the primary E&M code. So hopefully that will clear that up a little bit. It may cause more questions, but I want to introduce that as something that you can do. So let's pretend you have a postoperative complication and the patient of another doctor comes into you four weeks after incontinent surgery with bladder outlet obstruction, and you take her for sling removal. You are not a business partner with this patient, no, excuse me, with this other doctor. How are you going to code it? Well, you see the diagnosis there and also put that there is a mechanical complication of the graft, the urinary organ on there. Well, the modifier for this particular scenario is a 78 modifier. So what does that mean? A 78 modifier is an unplanned return to the OR by the same or other qualified health professional following initial procedure for a related condition. Now, the fact that you have a different business will actually, again, unlock that door for payment. So you need to be sure to use the 78 modifier when appropriate. So in summary, you need to use the right surgical codes. Um, I would, I would, I would really advise each and every person to, uh, subscribe to Augs Coding today. It's probably one of the most complete, uh, software, um, packages that you will find. You'll find, um, uh, the correct coding initiative, um, edits in there as well. It, uh, it'll tell you about all the modifiers, the RBU values, and, and, uh, global time frames. And so, um, so keep that in mind. Now, um, another thing we're going to talk about as well, and many of you may already know, that January the 1st of 2021, the conversion factor reduction will significantly reduce your reimbursement. So the government is devaluing your work. Um, and so, uh, that will be a separate thing that we need to talk about. Now, modifiers. Know the difference between 51 and 59 modifiers. Um, um, they, again, they unlock separate, uh, locks. And so you need to know about those. Use the modifier 24 in the office if you, uh, have the opportunity to do. And then, of course, the assistant modifiers and co-surgeon modifiers are important. Uh, with global time frames, understand that a day is added to the 90 and the 10 day modifier, excuse me, global time frames. And, um, um, and, and that day is generally just before the procedure is done. Uh, you also need to understand your business relationships with your other doctors to see if you can really, uh, uh, see what you can code for these procedures. So, um, finally, conversion factor. This is, again, what we talked about. Currently, the conversion factor is 36.08. The conversion factor is the amount of money per RVU that Medicare will pay you for a claim. Um, now, that conversion factor is going to dramatically drop to $32.58. And, again, your surgical services are being devalued by over 10 percent come January the 1st. Um, please call your congressman or congresswoman, as the case may be, to, uh, to help support getting rid of this. It affects every one of our businesses. I thank you very much for your attention and guns up. Back to Scott. All right, let me get my video started. And, Doug, if I can get you to unshare your screen. There we go. And then I'm going to share mine. There we go. So, our last sort of formalized part of this will be some coding challenges for you to think about. Um, and then we'll open it up to questions. We've already got three questions put into the Q&A section. If you've got questions, enter them into the Q&A section. You've got a little Q&A button. Type them in there, and we'll try to address them as a panel when we're done with that, when we're done with the formal part of this. So, you've been through coding for aerodynamics and office procedures. You've been through coding for surgical procedures. I just wanted to think a little bit about some of the pitfalls. Some of these have been mentioned a little bit in passing. I just want to spend a little more time thinking about them. Imagine a complicated scenario here. So, you've seen this 45-year-old lady who has stage 3 recurrent prolapse, and she comes to you wanting definitive surgical correction. After a prolonged discussion of her options and her likely outcomes, she opts for a robotic sacroecopal vaccine. During the course of this procedure, you note that after the placement of the graft, her right ureter is kinked, and it does not appear to be vermiculating as well as you would like it. So, you open the peritoneum separately. You dissect down to where the right ureter is. There, you discover a large mass of fibrotic scar tissue that looks like an old endometriosis and is adhering the ureter to her right utero-sacral ligament. So, you very carefully dissect it free, and after you dissect the ureter free of the scar tissue, it's found to be in its normal position with its normal movement working the way it's supposed to. You've solved a potential problem of ureteral kinking for her. How do you code for this? Well, the simple thought, the code for sacroecopal vaccine or laparoscopic sacroecopal vaccine is 57425, as Doug was just talking about. There is no specific code for a laparoscopic ureterolysis, but the open code for the procedure is 50715. So, the way you code for laparoscopic procedures that do not have a code of their own is not to use the open code, but rather is to use the unlisted code for that area of the body, and almost all the areas of the body have an unlisted code. This is what the unlisted codes are for. It's for procedures that don't have their own specific codes. So, you use an unlisted code, and then when you build that code, you will tell the payor what code is closest to what you did and what they should reference it to or compare it to. So, in this case, you'd build 50949, which is the unlisted code for laparoscopic procedures around the ureter, and you would reference it back to 50715. You'd combine that with the code of 57425, at least that's what would be suggested. So, you decide to code the combination 57425-51 and 50949 referenced to 50715 without the modifier, and you would put the modifier on 57425, because of course the RVUs for 50949 are higher, and lo and behold, time passes and you get a denial. Why did you get a denial? Fine analysis of this was all correct. These codes are all good. What's the problem with this? Well, you've just run up against what's called the National Correct Coding Initiative, the NCCI Edits, and by virtue of the NCCI Edits, 50715 is included in, it's part of 57425. Even though 50715 has higher RVUs than 57425, it's still considered to be part of the lesser procedure, and in fact, it can't be unbundled. So, there are codes that are bundled together, codes that are included in or which include another procedure that cannot be, that block cannot be broken, and there are some codes that can be broken with a modifier under certain circumstances. We'll talk about those in a second. You can bill for 57425. You can bill for 50715, or the equivalent of it is an unlisted laparoscopy code, but you cannot bill for both of them together. How do you sort this out? Well, you need to have a way to look at NCCI Edits and in the bundling, and part of the problem with that is that they are updated quite frequently, and so if you have a book from the beginning of the year, or worse, from last year or the year before, you may not have the current updated NCCI Edits, or, and I'm going to make a shameless claim now, you can go to Oggs Coding today. Doug's already talked about it a little bit. I use this tool every day. Literally, when I walk into my office and fire up my computer, I bring up my EMR, and I bring up coding today, because if I ever have a coding question in the middle of clinic, I can usually answer it in just a matter of seconds on coding today. If I have a question about my surgical coding, and typically when I do my surgical coding, I actually do it offline in the evening after I've gotten home, and I usually run everything through coding today before I submit the codes. That way, I know that at least I'm not going to run afoul of NCCI Edits or anything like that. It's an online tool. It's updated every time the edits are updated. It's a benefit that you get access to by virtue of your Oggs membership. You do have to pay for it. It doesn't come free, so it's a, it's an additional cost, but it is well, well worth it, something I use literally every day. And if you use Oggs Coding today, it has a tool that will allow you to look at CCI bundles. This is the CCI bundle that we just talked about, and if you look, you'll see that at the top of the, at the top of the area where the bundling matrix is, it lists only 57425, which was your primary code, and doesn't list the other code. This is the, this is the way they recommend that you bill it. This is how you would bill it, and then they provide you with an analysis, and if you look, you'll see a big red box that says never allowed to unbundle 50715 and 57425, so it tells you in nice, big, bright red color that you cannot do that. I'll give you another version of the same scenario, or of a similar scenario. 45-year-old with symptomatic stage 2 apical prolapse comes in wanting surgical correction, and after examined discussion, she decides upon a laparoscopic high utero sacral ligament fixation. Note a similar apical procedure, but a different code. At the time of the surgery, you find similarly her right ureter is densely adherent to the utero sacral ligament, again due to old fibrotic scar tissue, probably from old endometriosis, and once again, you very carefully and dutifully dissect her ureter free, and prevent her from having post-operative ureteral kinking, and you complete your high utero sacral ligament as planned. How do you code this? Well, in a similar way, you run it through your Coding Today bundling matrix. High utero sacral ligament fixation does not have a specific laparoscopic code, so again, this would be an unlisted code, 58999. There are a variety of codes you can reference it to. My personal preference is to use 57270, which is the code for an open enterocele repair, and if you look at the detailed descriptions of that procedure, it's very similar to what we do when we do a high utero sacral ligament fixation, so I consider that to be the closest representative of an equivalent code, and of course, the ureteral license is 50949, referenced to 50715. If you put those base codes into Coding Today, you will find that they are unbundleable, but they require a modifier. That modifier is the 59 modifier. It's a modifier that specifies distinct procedure. You made a separate incision in the peritoneum, you performed a ureteral license for a separate diagnosis, the endometriosis, retroperitoneal fibrosis, the scar tissue that's there, you did that because it was scarred down to the utero sacral ligament, not because it was part of the procedure itself. You need to clearly document those things in your op note, and I typically will add the diagnosis of retroperitoneal fibrosis if there's a lot of fibrotic scar tissue there, and that will make it clear to the payers as to why this is a separate procedure. There is a whole fact sheet on the OGS website about the use of the 59 modifier, because there are a lot of scenarios in which you will use this, and there are a lot of subtleties about that, so I strongly recommend you having a look at that. Let me give you an office procedure dilemma. One of your offices nurses is scheduled to perform urodynamics on a patient at 2 p.m. The patient arrives, the study begins. You're in the office dutifully seeing other patients, appropriately present and immediately available as required by the rules. At 2 30, while the urodynamic study is in progress, and part of the study has been done but other parts of it remain to be done, you are called urgently to the emergency room to see a post-op patient of yours who's bleeding. You proceed to the emergency department. The nurse completes the urodynamic study. What can you bill for? What can you not bill for? Well, this is a procedure we will talk about, we should talk about a little bit, but the bottom line is you can bill for the parts of this procedure that you were immediately available for. So, in this scenario, the complex uroflow has been done, you were there for that. You were not there for the completion of the system etrogram, the EMG, and the UPP remains to be performed. So, those you could not bill for because presumably you were not immediately available. There may be some subtleties. It depends a little bit on the dynamics of where you work. For example, if your office or clinic is located physically in the hospital building, you might reasonably be construed to be immediately available if the ER is in the same building. If you're on a hospital campus that has office buildings and a hospital but they're all in the same complex, it's possible that you may still be considered to be immediately available. If, for example, your patient is bleeding sufficiently enough that you need to take them to the operating room, however, even if you're in the same building, going to the operating room renders you not immediately available and so you would not be able to bill. So, that will depend a little bit on the subtleties of the exact scenario and where you are located. But, for example, if your office is a block down the street, you're clearly not immediately available. At this point, I'm going to open up the discussion to questions and answers. I'd ask the rest of the panelists to unmute themselves so that we can discuss questions. I'll go through the Q&A questions that are popped up and we'll see if we can talk through them. So, we had a question about neurodynamics and, Jessica, you had actually already flagged this one. If a patient is unable to avoid at the end of EDS, can you not bill for 51728, 51729, and 51797? So, let me let you take a stab at it. Yes, you can still, in my opinion, you can still bill for all those things. The 51797, you're still collecting intradermal pressure. The 51729 and 51728, if you do the pressure profile study, they don't have to avoid it. But, once you try to let them void and they're within the, you know, permission to void time, you're collecting information like they're voiding. Even if they aren't, you're collecting that the bladder squeeze or not squeezing if it's not. And so, I do think you can bill for those as well, even if they don't void. I would agree with that completely. And, in fact, that's the way I approach it, too. The general rule is, if you try, if you try to do a procedure and you diligently try to collect the data, you get to bill for it. The fact that you weren't able to actually fully get all the information you might have wanted doesn't mean that you didn't expend the effort, the energy, or obtain useful information from attempting to. So, I think I agree with you. I think that one can reasonably bill for it if you made the diligent college try to do it. Anybody else? All right, we'll move on to the next one. We have a question about management of OAB after surgery within the global period. Voiding dysfunction can be common after prolapse surgery, but not sure it's considered a complication. Doug, you want to take a stab at that one? Yeah, I agree. I think that overactive bladder, it certainly can be a complication, but honestly, I think it's a separate issue. And so, I would not hesitate to charge for it. I agree. I typically agree as well. It's a, you know, it's a different, yeah, it's a different diagnosis. I think you run into a fine line here because, you know, if the patient comes in for a post-operative visit, and that is the main reason that she's there, and rather than coming in for a specific complaint, I think, again, I think it's a fine line. I don't know that I would, you know, if just because you send her a prescription for an anticholinergic, I don't think that you can really charge an extra fee for that. However, if she comes in separately and says, you know, all of a sudden I just can't keep out of the bathroom after the surgery, this is, you know, I have terrible overactive bladder now, that's a separate complaint, and I think that is chargeable. Right, and I think it also sort of depends on where you are. So, for example, you know, if a patient comes in to see me a week after a surgery and is complaining of some OAB, I'm going to ascribe that to the inflammation and irritation of the surgery, and probably just let that one pass, even if I write her a prescription. But if she shows back up six weeks later and is still having this new complaint that she didn't have when she started before, then obviously we're treating a different issue, and if we have to start switching things around, then, you know, I think it's reasonable to start talking about going through that. I think you just have to be reasonable about that. Yes. Hey, Scott, I'd like to share my screen for just a second. Amy Park asked a question, and I think this is going to be a really good opportunity to show the power of aux coding today, if you don't mind. Please. So, let me see if I can get that. Can you see aux coding today on the screen? I certainly can. Okay, great. So, her question was, she thought the interaceal code was actually rolled in to the rectocele code, and the two could not be charged together. Well, here I have the interaceal code here, vaginal approach, okay, and if you look, hopefully, Amy, you're watching, but if you look down here in this bundling information, this is where the CCI bundles are kept. Look right here where my cursor is, and it says included in, and it says unbundling never allowed. So, if you just scroll through here, you will see that vaginectomy pops up. You just hover over the code, and vaginectomy can never be separately coded for with an interaceal. You can go through each one of these codes here, and I was doing that while Scott was talking, and I did not find

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rectal fecal incontinence surgery

apical pelvic repair

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