Make Sure Physician and Hospital Coding Matches


Make Sure Physician and Hospital Coding Matches

CODING Corner

Make Sure Physician and Hospital Coding Matches

Kim Charland

ADVANCE Columnist

As insurance companies begin to compare hospital and physician claims for similar information prior to payment, it is becoming more important for the ICD-9-CM and CPT codes assigned by each to match. The following information should correlate on the Health Care Financing Administration (HCFA) UB-92 and 1500 claim forms: dates of service; physician; referring physician; diagnoses; and procedures.

Many hospital claims are rejected because the CPT procedure code assigned does not match the one submitted by the physician. This illustrates an increasing need for accurate coding and how inappropriate code assignment can affect data quality and reimbursement.

The case study below shows coding assignments that led to a claims rejection—and those that would lead to payment.

Operative Report
Preoperative and Postoperative Diagnoses: Subglottic stenosis larynx

Procedures Performed: diagnostic laryngoscopy; tracheobronchoscopy; tracheotomy tube change; and excision of stoma lesions

The patient is brought to the operating room and given IV sedation anesthesia. The larynx is sprayed with 2% Xylocaine and the nose anesthetized with cocaine. A flexible fiber-optic adult laryngoscope was inserted, providing a good view of the larynx (31575) below the cords. The supraglottic larynx was normal and the appliance was in position. Then the old appliance was removed. There was significant concretion formation and crusting. This was coughed out, and the stoma was anesthetized with 2% Xylocaine. The bronchoscope was inserted through the tracheostomy, and a good view of the lower trachea and corina showed there were no further distal subglottic stenotic lesions (31615). Turning the scope superiorly, the vocal cords were competent, without lesions and with good motion.

The size 13 Montgomery T-tube was reinserted. A new one was placed (31502), and this could not be fashioned in position easily because it was twisted. The new tube was removed and replaced with marked difficulty. The patient tolerated well with good oximetry throughout. The appliance was in position, and the scope was used through the appliance to check position up and down, and to view the vocal cords and corina. The patient was breathing well. The plug was placed. At the stoma, several verrucca were excised with sharp dissection (31899) and sent to pathology. Bases were cauterized with silver nitrate. The patient tolerated this well and was released to home on Tylenol.

Pathology Report
Specimen: Tracheal stoma lesions

Preoperative and postoperative diagnoses: Subglottic stenosis

Diagnosis: Tracheal stoma lesions: Cicatrix and hyperkeratosis in squamous mucosa.

Gross exam: Specimen received in formalin in a container labeled with the patient’s name. It consists of three brown, irregular shaped portions of skin and underlying soft tissue. Portions range from 0.3 cm in greatest dimension to 0.8 x 0.3 x 0.2 cm. The largest portion has a central 0.2 umbilicated lesion.

Microscopic: There are three fragments of squamous mucosa with cicatrix and hyperkeratosis. Malignancy is not seen.

Code Summary
The hospital submitted the following codes:

ICD-9-CM Diagnosis Codes

478.74 Subglottic stenosis

478.9 Tracheal cicatrix

CPT Procedure Codes
31615 Tracheobronchoscopy through established tracheostomy incision

The physician submitted the following codes:
ICD-9-CM Diagnosis Codes

478.74 Subglottic stenosis

709.9 Skin lesions

CPT Procedure Codes
31631 Bronchoscopy; with tracheal dilation and placement of tracheal stent

11440 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

As you can see, the codes chosen vary. It is this fact that caused the payer to reject the claim. Both the hospital and the physician should assign the codes listed below.

ICD-9-CM Diagnosis Codes

478.74 Subglottic stenosis

478.9 Tracheal cicatrix

CPT Procedure Codes
31575 Laryngoscopy, flexible fiberoptic; diagnostic (31575-51)

31615 Tracheobronchoscopy through established tracheostomy incision

31502 Tracheotomy tube change prior to establishment of fistula tract (31502-51)

31899 Unlisted procedure, trachea, bronchi (31899-51)

Coding Rationale
The following four codes are required to capture all of the procedures performed:

  • 31575 for the initial diagnostic laryngoscopy
  • 31615 for the tracheobronchoscopy
  • 31502 for the change of the tracheotomy T-tube (Note: Removal of the old T-tube is not coded separately. It is assumed that the old tube would have to be removed before the new insertion).
  • 31899, an unlisted code, is assigned because there is no CPT code to describe the excision of stomal lesions.

On the HCFA 1500 form, remember to assign modifier -51 (multiple procedure to the CPT codes with the lower relative value unit).

* About the author: Kim Charland, a senior health care consultant at MedLearn, has more than 10 years experience in health information management. Her areas of expertise include ICD-9-CM and CPT coding for hospital ambulatory surgery, emergency department, anesthesia services and physician services.

About The Author