Hemoglobin concentrations in the high normal range in patients with anemia due to chronic kidney disease result in an excess risk of major adverse events, reported Arintaya Phrommintikul, MD, and colleagues from Monash University, Melbourne, Australia.

Adverse events include death, arteriovenous access thrombosis, and poorly controlled hypertension.

The investigators conducted a meta-analysis of 9 randomized controlled studies that enrolled 5143 patients treated with recombinant human erythropoietin.

Patients in the group targeted for a higher hemoglobin level (120-160 g/L) had a higher risk for all-cause mortality than patients in the lower hemoglobin target group (< 120 g/L) (risk ratio 1.17, P = 0.031).

There was also a higher risk for arteriovenous access thrombosis (risk ratio 1.34, P=0.0001) as well as a significantly higher risk of poorly controlled blood pressure (risk ratio 1.27, P=0.004) in the higher hemoglobin target group. The incidence of myocardial infarction was similar in the two groups.

Current guidelines recommend the maintenance of hemoglobin concentrations at 110 g/L or higher, based mainly on evidence of benefit in quality-of-life measures.

Current guidelines do not include an upper limit for the target hemoglobin concentration. The authors suggest that an upper limit should be added in future revisions of guideline recommendations.

The study was published in the 3 February 2007 issue of Lancet. 

Hemoglobin concentrations in the high normal range in patients with anemia due to chronic kidney disease result in an excess risk of major adverse events, reported Arintaya Phrommintikul, MD, and colleagues from Monash University, Melbourne, Australia.

Adverse events include death, arteriovenous access thrombosis, and poorly controlled hypertension.

The investigators conducted a meta-analysis of 9 randomized controlled studies that enrolled 5143 patients treated with recombinant human erythropoietin.

Patients in the group targeted for a higher hemoglobin level (120-160 g/L) had a higher risk for all-cause mortality than patients in the lower hemoglobin target group (< 120 g/L) (risk ratio 1.17, P = 0.031).

There was also a higher risk for arteriovenous access thrombosis (risk ratio 1.34, P=0.0001) as well as a significantly higher risk of poorly controlled blood pressure (risk ratio 1.27, P=0.004) in the higher hemoglobin target group. The incidence of myocardial infarction was similar in the two groups.

Current guidelines recommend the maintenance of hemoglobin concentrations at 110 g/L or higher, based mainly on evidence of benefit in quality-of-life measures.

Current guidelines do not include an upper limit for the target hemoglobin concentration. The authors suggest that an upper limit should be added in future revisions of guideline recommendations.

The study was published in the 3 February 2007 issue of Lancet. 

Hemoglobin concentrations in the high normal range in patients with anemia due to chronic kidney disease result in an excess risk of major adverse events, reported Arintaya Phrommintikul, MD, and colleagues from Monash University, Melbourne, Australia.

Adverse events include death, arteriovenous access thrombosis, and poorly controlled hypertension.

The investigators conducted a meta-analysis of 9 randomized controlled studies that enrolled 5143 patients treated with recombinant human erythropoietin.

Patients in the group targeted for a higher hemoglobin level (120-160 g/L) had a higher risk for all-cause mortality than patients in the lower hemoglobin target group (< 120 g/L) (risk ratio 1.17, P = 0.031).

There was also a higher risk for arteriovenous access thrombosis (risk ratio 1.34, P=0.0001) as well as a significantly higher risk of poorly controlled blood pressure (risk ratio 1.27, P=0.004) in the higher hemoglobin target group. The incidence of myocardial infarction was similar in the two groups.

Current guidelines recommend the maintenance of hemoglobin concentrations at 110 g/L or higher, based mainly on evidence of benefit in quality-of-life measures.

Current guidelines do not include an upper limit for the target hemoglobin concentration. The authors suggest that an upper limit should be added in future revisions of guideline recommendations.

The study was published in the 3 February 2007 issue of Lancet. 

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.