Submitting Clean Claims in 2003
The lesson that I've learned from the the revised 2003 CPT codes? If you expect to be paid, your codes must be very specific about what was done, where it was done and how it was done. It doesn't hurt to learn why it was done, either. I've selected a few new CPT codes to illustrate my point.

Catheter insertion
The new CPT code for insertion of an intraperitoneal cannula or catheter is 49419. It supplements existing codes 49420, 49421, 49422, 49423 and 49424. When preparing/dictating the operative note, physicians should include:

• Type of cannula/catheter. Different codes pertain to different types of devices, so make sure to indicate whether the device is temporary, permanent, or a totally implantable permanent catheter with a subcutaneous reservoir.
• Type of cannula/ catheter procedure. Indicate whether the surgeon inserted, removed or exchanged the device. Another possibility is that the procedure involved a contrast injection for diagnostic assessment of the patient.

Three codes have been added (51701, 51702 and 51703) and two deleted (53670 and 53675) for bladder catheterizations. Document whether the surgeon inserted a non-indwelling (51701) or temporary (51702 for simple and 51703 for complicated) indwelling catheter. Secondly, indicate the level of complexity of the procedure. Inserting a Foley catheter would be considered a simple procedure (51702). A patient with altered anatomy or the replacement of a fractured catheter or balloon would present sufficient surgical difficulty to use code 51703.

Contact Lolita M. Jones at '[email protected]').

Myomectomy
The three new code descriptions for myomectomy are very specific in terms of the number of myomas involved, their size and the surgical technique utilized:

• 58146. Myomectomy, excision of fibroid tumor(s) of uterus, five or more intramural myomas and/or intramural myomas with weight greater than 250 grams, abdominal approach.
• 58545. Laparoscopy, surgical, myomectomy, excision; one to four intramural myomas with weight of 250 grams or less and/or removal of surface myomas.
• 58546. Laparoscopy, surgical, myomectomy, excision; five or more intramural myomas and/or intramural myomas with weight greater than 250 grams.

These procedures could be difficult to code due to insufficient documentation if the physician provides vague clinical information. When coding these procedures, it's paramount that coders verify the number of myomas or fibroid tumors present, the anatomical location of the myoma (intramural or surface), the weight of the tumor (250 grams or less or greater than 250 grams) and the surgical approach utilized (open surgery via the abdomen or vagina, laparoscopic surgery or hysteroscopic surgery).

Spinal injections
The existing list of CPT codes for spinal injections is already lengthy (62263, 62280-62282, 62310-62319, 64400-64530, 64600-64680) and there are four new codes in 2003.

• 64416. Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement), including daily management for anesthetic agent administration.
• 64446. Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement), including daily management for anesthetic agent administration.
• 64447. Injection, anesthetic agent; femoral nerve, single.
• 64448. Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement), including daily management for anesthetic agent administration.

As with myomectomy, you must include quite of bit of specific procedural information to code and bill these cases and ensure they are reimbursed in a timely fashion. First, coders must know the medical substances injected into the spine. Possibilities include lysis solution (hypertonic saline), anesthetic agents, anti-spasmodics, opioids, steroids, neurolytic substances (alcohol, phenol and iced saline solution) or the application of thermal, electrical or radiofrequency energy. Second, they must know whether the injection was done via an indwelling catheter.

Your clinical documentation must indicate the type of injection: single, multiple, differential, continuous infusion or intermittent bolus. Here's a little background in the procedures.

• Single injections are one-time injections administered either intrathecally or epidurally via lumbar puncture.
• The record should indicate multiple or regional injections if the doctor gives a series of intrathecal or epidural injections. The patient is assessed after each injection; at least one of the injections is of normal saline. Two indicators of this technique: when major psychological issues affect a patient's treatment strategy or when you're considering several drugs.
• Differential injections involve local anesthetics of varying strengths and a placebo injection to help identify the source of pain.
• In continuous infusion, the doctor may place a catheter either intrathecally or epidurally and connect the catheter to an external infusion pump. Drug therapy is tested over a period of days to weeks. This method is used to mimic an implantable system.

Physicians must indicate the anatomical sites of the injections (brachial plexus and sciatic nerve) because the only difference between some of the CPT codes is the injection site. Plus, there are subdivisions within each anatomical site. For example, different codes pertain to injections in the lumbar area (epidural, subarchnoid and transforaminal). One especially tricky coding challenge is for sympathetic nerve injections. There are different codes for sphenopalatine ganglion, carotid sinus, stellate ganglion/cervical, sympathetic lumbar paravertebral sympathetic thoracic paravertebral and sympathetic celiac plexus injections.