May 27, 2022

Mark, Scott, and Ray discuss questions that came into the PRS Community Forum.

1. Independent historian. For pediatric visits, I'm a little unclear what counts as an independent historian. I see the definition from CMS indicates "an individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary."

Does a parent providing a history count as an independent historian for a baby? I can see an argument for no (i.e. "provides a history in addition" to the patient's history - baby provides no history) but also for yes (baby isn't able to provide history due to developmental stage). Curious your thoughts on this.

2. Newborn (post-hospitalization) circumcision consult. Trying to determine how this one is billed. Not talking about the routine circumcisions that happen right after birth (usually done by OB/pediatrics anyways) but rather about the ones referred to pediatric urology because the parents wanted a circumcision but peds / OB didn't think they should do it because of concern for something like penile torsion. 
- Risk: I presume would be level 4 (minor procedure with risk factors).
- Problem: I'm not sure about this one. I presume if something like penile torsion is noted on exam, this would be a level 4 problem (chronic not at treatment goal). What if it turns out the exam is normal? Is it still chronic not at treatment goal because the parents / patient desire circumcision? This seems to be the key question for whether this visit type would be a level 3 or 4. 
- Data: perhaps irrelevant if problem and risk are 4's, but perhaps a 3 (independent historian) or just a 2 (review of outside records).

3. This is a question posed by our ASC.
I appealed the insurance denial and they upheld the denial stating “Our review, with medical records, has determined that per published evidence-based coding literature the following diagnosis code(s) is not compatible with the procedure code(s) billed: T19.1XXD and 52310.” They state “the specific code combination listed above was denies based on published evidence-based coding literature. There is a more appropriate diagnosis code for the procedure billed per medical record documentation which states removal of ureteral stent, not a foreign body; please submit corrected claim.”

What more-appropriate diagnosis code is there? History was of UPJ stone with hydronephrosis, since resolved on one and ureteral stone, also resolved, on the other. Because the conditions were treated during surgery, the only reason the patient was coming back in was for removal of the ureteral stone and we’ve always used T19.1XXD w/out issue for that. Other possibilities I’m finding are Z46.6 (Encounter for fitting and adjustment of urinary device) or T83.192D (Other mechanical complication of indwelling ureteral stent, subsequent encounter) but they don’t feel appropriate.

4. Do you have experience with the code 0421T? I need to come up with RVU's to assign to the Temporary code 0421T. (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed). I see other health systems with a definitive RVU number. Can you offer guidance on how to assign a RVU to this procedure?

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