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CHAPTER 26

CHAPTER 26. MEDICINE. Medicine Section. Diagnostic and Therapeutic Procedures Most procedures noninvasive (not entering body) Contains invasive procedures Example: 92973, Percutaneous transluminal coronary thrombectomy Numerous notes throughout. Subsections. Wide variety of services

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CHAPTER 26

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  1. CHAPTER 26 MEDICINE

  2. Medicine Section Diagnostic and Therapeutic Procedures Most procedures noninvasive (not entering body) Contains invasive procedures Example: 92973, Percutaneous transluminal coronary thrombectomy Numerous notes throughout

  3. Subsections Wide variety of services Many specialized tests Examples: Audiology Biofeedback

  4. Immunizations Often used Two types of immunizations Active and passive Correct coding includes Supply injected Administration of injection

  5. Active—Bacteria or Viruses Bacteria that cause disease made nontoxic (toxoid) Injected to build immunity Small dose active virus injected (vaccine) Injected to build immunity Example: Poliovirus

  6. Passive Immunization Does not cause immune response Contains antibodies against certain diseases—immune globulins

  7. Immune Globulins (90281-90399) (1 of 2) Identifies immune globulin product Example: Botulism antitoxin Report administration separately

  8. Immune Globulins (90281-90399) (2 of 2) Codes divided by: Type e.g., Rabies, hepatitis B Method e.g., Intramuscular, intravenous, subcutaneous Dose e.g., Full dose, mini-dose

  9. Immunization Administration for Vaccines/Toxoids (90460-90474) (1 of 2) Administration (performing the injection) of substance Reported with substance given

  10. Immunization Administration for Vaccines/Toxoids (90460-90474) (2 of 2) 90460, 90461 Patients through age 18 when physician counsels regarding immunization 90471-90474 = Patients 19 years of age or over Patients of all ages (including under 19) if physician does not counsel regarding immunization 90471, +90472 = Percutaneous, intradermal, subcutaneous, or intramuscular injection 90473, +90474 = Oral or intranasal

  11. Methods of Administration Percutaneous Intradermal Subcutaneous Intramuscular • Intranasal • Oral From Bonewit-West K: Clinical Procedures for Medical Assistants, ed 8, St. Louis, 2012, Saunders.

  12. Report Administration for Each Dose—Single or Combination Example: Patient (over age 8) receives three separate administrations: 90471 tetanus 90472 rubella (add-on code) 90472 diphtheria (add-on code) OR depending on payer: 90471 tetanus 90472 x 2 rubella and diphtheria

  13. Vaccines, Toxoids (Vaccine Product Codes) (90476-90749) Many codes are age or dosage specific Example: 90658, Trivalent (IIV3) influenza virus vaccine, split virus, 0.5-mL dosage Codes for products for single diseases Example: 90713, Poliovirus vaccine, inactivated (IPV) Codes for combination of diseases Example: 90700, Diphtheria, tetanus, and acellular pertussis (DTaP) Caution: There are numerous code combinations of diphtheria

  14. Vaccines, Toxoids Some vaccines given on schedule Example: 90633, 2-dose hepatitis A vaccine First dose, first visit Second dose, second visit 90633 is reported for each visit

  15. Remember Do not assign modifier -51 with Vaccine/Toxoid codes Rather, depending on payer: List each code multiple times or Use times (x) symbol and indicate number Modifier -51 should not be reported for the vaccines, toxoids when performed with these administration codes (90460-90474)

  16. Important Reporting Rules If vaccine administered during office visit (not related to E/M) Report E/M service with modifier -25 + Vaccine + administration Depends on local carrier Office visit for vaccine only, code only vaccine, NO E/M service Depends on local carrier

  17. Routine Vaccinations Influenza Administration G0008 HCPCS (Medicare only) 90471/90472 Substance (trivalent (IIV3) influenza virus vaccine) 90657, 90658 Pneumococcal Administration G0009 HCPCS (Medicare only) 90471/90472 administration Substance (23-trivalent pneumoccal polysaccharide vaccine) 90732

  18. Psychiatry (90785-90899) (1 of 3) Psychiatric treatment at same time as E/M service, report One code for therapy with E/M Example: 90833, psychotherapy and E/M Time major billing factor Codes divided on time Medical record indicates session time

  19. Psychiatry (90785-90899) (2 of 3) • When selecting a psychotherapy code ask these questions: • How much face-to-face time is spent with the patient? • Does documentation support an evaluation and management code in addition to psychotherapy? • If rendering psychotherapy, is the approximate “time” of the psychotherapy noted in the medical record?

  20. Psychiatry (90785-90899) (3 of 3) Many services provided in partial hospital settings Patient in hospital during day, returns to home for evenings and weekends Interactive psychotherapy is typically furnished to children It uses play equipment, physical aides, nonverbal communications, or other mechanisms of communication

  21. Biofeedback (90901, 90911) (1 of 2) Used to help patients gain control over body processes Example: High BP or chronic pain Medicare Coverage Issues Manual 35-27 restricts the use of biofeedback Medicare doesn’t cover biofeedback for psychosomatic disorders

  22. Biofeedback (90901, 90911) (2 of 2) Patient training in biofeedback by professional Continues on own Services often part of psychophysiologic (mind/body) therapy

  23. Dialysis (90935-90999) Cleanses blood Temporary (non-ESRD) Permanent (ESRD) Two parts to report ESRD dialysis services: Physician service Hemodialysis procedure Figure 26.4 Patient receiving hemodialysis. (From Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera IM: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, ed 8, St. Louis, 2011, Mosby.)

  24. End Stage Renal Disease Services(90951-90970) Include Establishment of dialyzing cycle Physician services E/M outpatient dialysis visits Patient management during dialysis Reported for month: 90951-90966 Less than full month of service: 90967-90970 per day Codes divided on age and number of visits

  25. Hemodialysis Service (90935-90940) Hemodialysis is the procedure Used for ESRD and non-ESRD Billed per day for inpatients receiving ESRD + non-ESRD Includes all physician E/M services related to procedure Use modifier -25 if separate E/M service provided

  26. Miscellaneous Dialysis Procedures (90945-90947) Describes other dialysis procedures Example: Peritoneal dialysis in which toxins are passively absorbed into dialysis fluid

  27. Peritoneal Dialysis Services billed on per day basis for inpatient ESRD patients From Goldman L, Ausiello D, editors: Cecil Textbook of Medicine, ed 22, Philadelphia, 2004, Saunders.

  28. Dialysis Training Patients can receive training in self-dialysis Reported with 90989, 90993 Codes divided by complete or partial training program

  29. Gastroenterology (91013-91299) For tests and treatment of esophagus, stomach, and intestine Codes usually reported with E/M or consultation service code Caution: Many bundled services

  30. Ophthalmology (92002-92499) (1 of 2) Contains E/M codes Not E/M codes from front of CPT Definitions for new and established patients same as for E/M section Most codes are for bilateral services If only one eye, use modifier -52(reduced service) Read the definitions of intermediate and comprehensive services in the CPT!

  31. Ophthalmology (92002-92499) (2 of 2) • Example, Intermediate: Review of history, external examination, ophthalmoscopy, biomicroscopy for an acute complicated condition (e.g., iritis) not requiring comprehensive ophthalmological services • Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision making cannot be separated from the examining techniques used

  32. Special Otorhinolaryngologic Services (92502-92700) (1 of 2) For special evaluations of audiologic system Go beyond those usually provided in evaluation May be reported in addition to basic audiologic service

  33. Special Otorhinolaryngologic Services (92502-92700) (2 of 2) Special treatments and diagnostic services Example: Nasal function tests (rhinomanometry) or audiometric tests All hearing tests bilateral unless indicated one ear in description Use modifier -52 for 1 ear Nasal function test equipment. (From Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, Thomas JR: Cummings Otolaryngology-Head & Neck Surgery, ed 5, Philadelphia, 2010, Mosby.)

  34. Coronary Therapeutic Services and Procedures PTCA (92920-92921) Access through the femoralor brachial artery Catheter with balloon tip threaded up to heart Balloon is expanded and widens vessel If an angioplasty and an atherectomy are performed during the same session, only the atherectomy is billed If a stent is placed in a coronary vessel, the stent placement takes precedence over the atherectomy Stent(s) placement(s) includes coronary angioplasty when performed (92928, 92929)

  35. Cardiography (93000-93278) Implantable, Insertable, and Wearable Cardiac Device Evaluations (93264, 93279-93299) And Echocardiography (93303-93355) Reviewed in Chapter 17 of this text

  36. Cardiac Catheterization Diagnostic medical procedure Three components included in most Cardiac Catheterization Codes: Catheterization Injection Imaging Congenital cardiac catheterization codes (93530-93533) do not include injection or imaging Reviewed in Chapter 17 of text

  37. Anticoagulant Management (93792, 93793) Outpatient management of warfarin therapy Training for INR monitoring 93793 billed once per day, any number of tests reviewed

  38. Noninvasive Vascular Diagnostic Studies (93880-93998) Vascular codes for procedures on noncoronary veins and arteries Includes Patient care Supervision and interpretation (S&I) Copy of results Reviewed in Chapter 17 of text

  39. Pulmonary (94002-94799) For ventilation management, therapies, and diagnostic tests Includes procedure and interpretation of test results Additional E/M service reported separately Ventilator management codes Further divided by place of service Facility is billed per day Home billed by time once per month

  40. Allergy and Clinical Immunology (95004-95199) Divided into three subheadings: AllergyTesting (95004-95071) Ingestion Challenge Testing (95076, 95079) AllergenImmunotherapy (95115-95199) Allergy Testing—consists of performance, evaluation, and interpretation of allergens Ingestion Challenge—test for sensitivity to food, drugs, and other substances Immunotherapy—indicated for patients with allergic rhinitis due to seasonal pollinosis caused by trees, grasses, weeds, etc.

  41. Allergy Testing (95004-95071) Sensitivity testing using various types of tests Example: Percutaneous, intracutaneous, inhalation Tests use numerous substances Example: Extracts, venoms, biologics, and foods Typeand number of tests based on physician’s judgment Medical record will indicate the Number of tests Type of test Method of testing

  42. Ingestion Challenge Testing (95076, 95079) Sensitivity to food, drugs, and other substances 95076 reports initial 120 minutes testing time 95079 reports each additional 60 minutes Services less than 60 minutes, report E/M code

  43. Allergen Immunotherapy (95115-95199) (1 of 2) Codes divided into three types of services: Injection only Prescription and injection Provision antigen (substance) only Codes 95115 and 95117 are payable in an office setting

  44. Allergen Immunotherapy (95115-95199) (2 of 2) Physician service bundled into immunotherapy codes If separate E/M service provided, report separately with modifier -25

  45. Neurology and Neuromuscular Procedures (95782-96020) Contains codes to report tests, such as: Sleep testing Muscle and range of motion testing Electroencephalography (EEG) Neurostimulator procedures Functional brain mapping Many bundled services Services usually provided in addition to E/M service These are often consultative services (e.g., 99241-99242)

  46. Central Nervous System (CNS) Assessments/Tests (96105-96146) Used to report: Psychological tests Speech/language assessments Developmental progress assessments Thinking/reasoning examinations

  47. CNS Assessments/Tests Codes based on time Includes written report of results

  48. Hydration (96360, 96361) 96360-96361 Infusion: Therapeutic procedure to introduce fluid into body Example: Fluid into vein for patient rehydration Codes represent infusion service and “prepackaged fluid and electrolytes” Other than prepackaged, report separately

  49. Hydration, Therapeutic Infusions, and IV Pushes Only one initial service per encounter Patient presents for hydration (initial service) Has drug therapy while being hydrated Drug therapy is subsequent Report with add-on code Example: 3 hours hydration with antiemetic by IV push for 15 minutes 96360 = hydration, 1 hr 96361 × 2 = hydration, hr 2 and 3 96375 = antiemetic IV push

  50. Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration) (96365-96379) Types of Drug Administration Therapeutic • Prophylactic • Diagnostic Codes divided by administration method Subcutaneous • Intramuscular • IV Push • Intra-arterial • Intravenous push A push takes 15 minutes or less Over 15 minutes is an infusion Also report the substance administered (J code)

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