Coding For Ambulatory Procedure Visits (APVs) and Observations by aah15699

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									 Headquarters U.S. Air Force
 Integrity - Service - Excellence

Coding For Ambulatory Procedure
               Visits (APVs) and
                   Observations


                      Shirley M. Zoblosky, RHIT
                                  AFMOA/SGZZ
                                          W302



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                                                                UNCLASSIFIED

                                                     Objectives

      Learn the coding rules applicable to Ambulatory Procedure Visits
      (APVS) and Observation encounters
         Identify primary diagnosis (using pathology report)
         Sequence multiple diagnoses
         Use of CPT procedure codes and modifiers
         Identify postoperative complications
         Understand requirement for admission to inpatient status
         Know how to use anesthesia code
         Comprehend guidance for global surgical package coding




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                                                   Objectives

     Learn DoD guidelines as they apply to Observation Units

     Understand the assignment of multiple Evaluation & Management
      codes to capture stays on observation units over 36 hours

     Know documentation issues relating to APVs and Observations

     Recognize disposition types for APVs and Observation Encounters

     Understand impact DoD billing has on the coding of outpatient
      visits




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                                                              UNCLASSIFIED

                                        What Is An APV?

     APU – Ambulatory Procedure Unit
        Unit dedicated to performing ambulatory surgery
        B**5
        B**7
        C**5
        Generally, 23 hours – 59 minutes
     APV – Ambulatory Procedure Visit
        Encounter when a outpatient procedure is to be performed in a
         APU
        Only ambulatory procedure visits are coded with the APV
         MEPRS




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                           What Is An APV? (Cont.)

     Coding the Ambulatory Data Module (ADM) record
        Primary diagnosis will be primary reason for surgery
        Code postoperative diagnosis, if different from preoperative
           Example:
           Preoperative diagnosis-breast mass (611.72)
           Postoperative diagnosis from pathology report - carcinoma
            in situ, breast (233.0).
        Code co morbidities (if relevant to patient outcome) and/or
         complications
           Example:
           Hypertension
           Postoperative hemorrhage




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                                                               UNCLASSIFIED

               Sequencing of CPT Procedures

     Sequence first the CPT procedure with the greatest risk or the
      most expensive
     Sequence second the procedure with the next greatest risk or next
      expensive, etc.
     Anesthesia CPT and HCPCS codes are also listed in procedure
      section
     Failure to sequence properly can result in
        Claims denial
        Incorrect payment




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                                                      Modifiers

     Special designators which add to the description of a major code
     Base code
        CPT/HCPCS
     Modifier
        Added to CPT or HCPCS code




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                                  Modifiers (Cont.)

   Service or procedure has both a professional and technical
    component
   Service or procedure performed by more than one physician
    and/or in more than one location
   Service or procedure increased or reduced
   Only a portion of service performed
   Bilateral procedure performed
   Adjunct service performed
   Service or procedure provided more than once
   Unusual events occurred




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                                    Modifiers (Cont.)

   50 - Bilateral procedures
      Bilateral procedures performed at the same operative
        session
          NOTE: Modifier 50 must not be used for surgical
           procedures identified by their terminology as “bilateral”
          Surgical procedures identified as “unilateral” or
           “bilateral”
               Example
                   27395          Lengthening of hamstring, tendon,
                    multiple, bilateral
               Example
                   52990          Cystourethroscopy, with
                    meatotomy, unilateral or bilateral


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                                    APV Preoperative
                                        Appointment

   57 - Decision for surgery
      An evaluation and management service which results in the
        initial decision to perform the surgery
   APV Preoperative Appointment
   Document in ADM as separate encounter if not day of surgery
      No APV indicator checked
   Prior to decision to perform surgery
      Office visit E/M code
      Consultation E/M code




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                                 APV Preoperative
                               Appointment (Cont.)

   Services provided day decision made to perform surgery
    either:
      Office visit E/M code
         99201 – 99205
         99211 – 99215
      Consultation E/M code
         99241 – 99245
      Modifier 57 to E/M code
         Decision for surgery




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                                   APV Preoperative
                                 Appointment (Cont.)

   Services provided after decision for surgery – prior to surgery
      99499 E/M code
         Professional services are included in procedure code
         Document in ADM as separate encounters




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                                  APV Postoperative
                                      Appointments

   Document in ADM as separate encounters
      No APV indicator checked
      Most surgical procedures include pre and postoperative
       services.
      E/M code 99499
      CPT procedure code 99024




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                                 APV Postoperative
                               Appointments (Cont.)

   Follow center for Medicare and Medicaid Services (CMS)
    timelines for postoperative follow-up sessions
      Endoscopic or minor procedure with related preoperative
       and postoperative relative values on day of procedure only
         000 days
      Minor procedure with preoperative relative values on day of
       procedure and postoperative relative values during 10 days
       postoperative period
         010 days
      Major surgery with one (1) day preoperative period and 90
       days postoperative period
         90 days




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                               Preoperative and
                        Postoperative Exceptions

   Exceptions to previous slides are few
      * (Starred procedures) in the CPT code book
         Includes procedures only
         Pre and postoperative services not included
         Visits coded using appropriate E/M
              Office Visit
                  99201 – 99205
                  99211 – 99215
              Consultation
                  99241 – 99245
              Do not use 99499 with * procedure




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                                            APV Status

   Continue APV status
      Released
      Admitted as inpatient
         Regardless patient’s bed location
   Observation or holding beds will not be reported as APV
    services




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                       APV Complications

   APV status until admitted as inpatient
       Closeout the ADM record
       Disposition type “admitted”
       Procedure codes from APV not included with the
        inpatient stay
       Diagnosis for admission is the reason requiring
        acute admission
           Complication




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                                     APV Anesthesia

   Coded when procedure performed (00100-01999)
   Anesthesia codes entered in procedure (CPT) section
      Matched to same diagnosis as surgical procedure
   Code any anesthetic agent administered
      HCPCS J-code in procedure section
   Anesthesia will be billed based on Units of Service of “1”
      Flat rate billing




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                       APV Anesthesia (Cont.)

   Provider performing procedure
      Primary provider
      Responsible for ADM
      Anesthesiologist
      Certified Registered Nurse (CRNA)
      Anesthesiologist Assistant (AA)
         Listed as additional provider
   Modifiers that apply to anesthesia services
      –QX and -QZ will be used for CRNA and AA
      -QK and –QY modifier identifies Anesthesiologist only




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                      APV Anesthesia (Cont.)

   Two primary surgeons working together performing distinct
    parts of a single reportable procedure
      Modifier -62 will be used for each surgeon
   Two surgical teams performing different procedures on
    different body systems during same encounter
      Sequence most revenue intense procedure first
      Modifier -62 will be used for each surgeon




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                            Conscious Sedation

   99141-99142 in ADM procedure section
      Also code anesthesia
         HCPCS J Code if available
      Administered by privileged provider also performing
       procedure
         Requires presence of independently trained observer to
           assist provider in monitoring
              Level of consciousness
              Physiological status
      If administered by other than the privileged provider
       performing the procedure
      Anesthesia Codes 00100-01999




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                                      APV Canceled

   Patient presents, and APV not performed
      Medical condition
      Provider not able to perform APV
      Supplies or resources not available
   Coding of canceled procedures when patient presents
      Diagnosis
         Initial diagnosis for performing procedure
         V64* series code to indicate why canceled
         Code any medical conditions that prevented procedure
          from being carried out




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                           APV Canceled (Cont.)

      E/M
         99499 in most instances
         Services provided other than APV
             Appropriate E/M code
   APV cancelled prior to patient’s arrival
      No ADM record generated




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                                    Units of Service

 Some E/M codes are based on time
    Units of service can now be entered into the Ambulatory
     Data Module (ADM) if appropriate
 A unit of service is amount of time, supplies or days that a
  particular CPT or HCPCS code is supplied one or more times
 Units of service are triggered when the provider indicates how
  many times the procedure was performed
 For timed codes, the entire time frame must be completed
  before it can be considered a unit of service
 For modifier -50, bilateral procedures, the Unit of Service will
  be defaulted to “1” and the rate will be multiplied by “2” to
  show the procedure was performed twice



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                          Observation Services

   Purpose of an Observation Unit is to determine whether patient
    needs to be admitted, transferred to another MTF or sent home
   Use E/M codes to document length and acuity of observation
    services in ADM
   Observation E/M codes relate to
      Number of calendar days patient spends in observation
          Up to three (3) E/M codes may be used when necessary
           for stays up to three 3 days
   Services provided in an emergency department or clinic visit
    will be included in Observation services, if provided on the
    same date




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                                                  Hospital Observation
                                                            E/M Codes
   LENGTH OF OBSERVATION (CALENDAR              DAY OF              OBSERVATION E&M
            DAYS OR DATES                      SERVICE              CODES FOR ACUITY
                                                            LOW         MEDIUM         HIGH
Initial Observation care when length of stay     Day 1      99218        99219         99220
exceeds calendar day of admission to
observation.
Observation care services provided when          Day 1      99234        99235         99236
patient is admitted and discharged on same
calendar day of service
Observation care on a day not the admission     “Middle     99499        99499         99499
and not the discharge day.                       Days”
Observation care services provided on day of   Day 2 or 3   99217        99217         99217
discharge (unless day of discharge is day of    (date of
admission ) across 2 or more calendar days,    discharge)
but not exceeding a total of 48 hours of
observation care.




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                              Observation (Cont.)

   Only supervising provider may report initial observation care
    code which includes:
      Initiation of observation
      Supervision of care
      Periodic assessments
   Observation by other providers
      Consultation codes
         99241-99245




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                               Observation (Cont.)

   Admitted to observation from ER or clinic office
      Only report initial observation care code for all E/M services
       that date
         99218-99220
   Patient placed in observation, not discharged that day
      One initial observation care code
         99218-99220
              Dependent on acuity
   Patient placed in and released from observation same day
      One observation care services code (Includes admission
       and discharge)
         99234-99236




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                                 Observation (Cont.)

   Patient placed in observation for two or more calendar days not to
    exceed 72 hours
      Observation care discharge services on date of discharge
         99217
   Observation stay spans over three calendar days
      Middle day of observation
         99499
   Patient should not stay longer than 72 hours in observation
   Professional services and outpatient coding guidelines
      Table 3.2 on page 3-7
         E/M codes for observation services




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         Non-Covered Observation Services


   Observation services exceeding 24 hours, unless exception
    deemed necessary, following medical necessity review
   Services provided for convenience of patient, family or
    physician
   Inpatient services
   Services associated with APVs
   Routine preparation for testing in a hospital outpatient
    department, e.g., diagnostic testing
   Observation concurrent with treatments, e.g., chemotherapy
   Postoperative monitoring




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         Non-Covered Observation Services
                                  (Cont.)

   Any substitution of outpatient observation service for
    medically appropriate inpatient admission
   Services ordered as inpatient but reported as outpatient
    observation by the hospital
   Standing orders for observation following outpatient services
   Discharge to outpatient observation after inpatient hospital
    admission
    NOTE: Remember non-covered services should not be entered
    into ADM




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                                         Observation

   Admitted from observation
      Close out ADM record with disposition of “admitted”
   Referred from observation to APU or other MTF
      Close out ADM record with disposition of “immediate
       referral”




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                            Questions




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