Chapter 8

1. Chapter 8 Medicine

2. Introduction • Diagnostic, therapeutic, and miscellaneous procedures and services • Health-care providers other than physicians have unique service codes • Special service codes • i.e., outside of normal office hours

3. Common Modifiers • -25 • Separately identifiable evaluation and management service by the same physician on procedure day • -50 • Service code represents unilateral procedure, it is provided bilaterally • -52 • Services provided are less than the full code describes • -59 • Encounter has occurred on the same day and codes have already been billed for those services

4. Injections and Infusions:Immune Globulins • Immune globulins provide protection against certain diseases • Injections • Intramuscular • Subcutaneous • Intravenous

5. Injections and Infusions:Vaccination and Toxoid Administration • Immunity: body produces antibodies in response to antigen exposure • Antigens: Bacteria, viruses, fungi • Route of administration • Percutaneous • Intradermal • Subcutaneous • Intramuscular • Intranasal • Oral • Age of patient • Number of administrations: Add-on codes for “each additional” • Two codes are required: Administration and vaccine or toxoid product injected

6. Injections and Infusions: Hydration • Hydration: administration of prepackaged fluid and electrolytes (not drugs) • Codes are based on time • 96360 – one hour • 96360 should not be used as the initial service if a patient is also treated with a medication • Example: Patient with nausea and vomiting receives IV fluids and then Phenergan IV push (through the IV). Code Phenergan administration as the initial service and fluids as 96360 • 96361 – add-on for each additional hour

7. Injections and Infusions • Therapeutic, prophylactic, and diagnostic • Codes based on route and time • First hour, each additional hour • Medication supply codes: depends on payer requirements • Assign a “J” code from HCPCS Level II • If payer will not accept “J” code, assign 99070

8. Injections and Infusions • Injection and infusion codes include the following services: • Local anesthesia • Starting the IV • Establishing access to the IV (catheter or port) • Flushing of the line at the conclusion of infusion • Supplies • Preparation of the substance(s) to be infused

9. Injections and Infusions • Concurrent infusions: multiple substances administered through one IV site but separate bags • Piggybacking • Add-on code reported once per encounter • Modifier -59 used for second encounter • Intravenous and intra-arterial push • Codes only used when provider is present or infusion takes less than 16 minutes • Code as subsequent if push is given after starting a separate infusion (not initial service)

10. Psychiatry • Codes are provided for inpatient and outpatient services • Psychotherapy codes • Based on face-to-face time: may be reported by psychologists, social workers, counselors • Health assessment and medication monitoring: must be used by psychiatrist (or other physician), nurse practitioner, or physician assistant • Family psychotherapy • Provided with or without patient present

11. Dialysis Hemodialysis for ESRD • End-stage renal disease (ESRD): 15% of kidney function remains • Hemodialysis: removes waste products of metabolism from the bloodstream • Coding in the outpatient setting • One full month or per day services • Age • Codes include the following services: • Dialysis cycle • Care provided during visit • Evaluation and management services • Telephone calls relating to the care • Nutritional assessment and review, growth monitoring, and parental counseling and support (if younger than 20 years)

12. Dialysis • Coding in the inpatient setting for ESRD and non-ESRD patients • If the physician is present during hemodialysis (90935–90940) • Peritoneal dialysis or services other than hemodialysis (codes 90945–90999) • Codes available for single evaluation or repeated evaluations by physicians

13. Gastroenterology • Gastroesophageal reflux disease (GERD) • Acid in esophagus, changes pH • Tests for pH • Manometric studies for motility • Capsule endoscopy: “camera pill”

14. Ophthalmology • Ophthalmology: the study of the eye • 92002–92014 For new and established patients • Ophthalmoscopy and dilation of pupils not coded separately • Examples of procedures that are coded: • Fluorescein angioscopy: determine the blood supply to the retina • Tonography: determine pressure within the eye • Visual field testing: defects in the field of vision

15. Otorhinolaryngologic Services • Otoscopy, rhinoscopy, hearing tests (using tuning forks, whispered voices) are part of E/M services routinely provided • Auditory rehabilitation: testing for hearing loss and speech understanding • Codes are based on time: first code for 1 hour and add-on code for each additional 15 minutes • Codes also provided for patients with hearing loss before beginning speech and after learning speech

16. Cardiovascular Services:Electrocardiography • Tracing of the electrical activity in the heart • Physician’s office procedures include: • Entire procedure • Provision of a tracing only • Provision of interpretation and report only • Holter monitor: portable device providing 24-hour tracings of electrical activity of the heart

17. Cardiovascular Services: Echocardiography • Ultrasound of the heart chambers, valves, great vessels • 2D or Doppler • Complete or limited studies • Transthoracic • Transesophageal

18. Component coding One catheter placement code All applicable injection procedure codes Imaging supervision and interpretation codes Cardiovascular Services:Cardiac Catheterization

19. Procedures included in cardiac catheterization codes and not coded separately Catheter insertion (percutaneous or cut-down) Positioning and repositioning of catheters Injection of dyes (site of angiography) Recording of intracardiac and intravascular pressures Obtaining blood samples for gas analysis or dilution curves Cardiac output measurements Pharmacologic administration Cardiovascular Services:Cardiac Catheterization

20. Cardiovascular Services: Percutaneous Transluminal Coronary Angioplasty (PTCA) • Percutaneous coronary intervention (PCI) • Used if blockage is found during catheterization • Coding for stenting • PTCA is not coded separately, catheterization is coded separately • Stenting codes are assigned for each vessel • Multiple stents in one vessel is coded as one stenting • Coding for atherectomy • PTCA is not coded separately, catheterization is coded separately

21. Cardiovascular Services:Electrophysiologic Procedures • Electrophysiologic studies (EPS) and mapping • Performed to determine the areas of damaged tissue in the heart that cause arrhythmias • Atrial fibrillation • Ventricular tachycardia • Intracardiac catheter ablation is performed to destroy the aberrant tissue • EPS, mapping, and ablation usually done on the same day

22. Pulmonary Services: Mechanical Ventilator • Device used to assist the patient with breathing • Codes based on initial day or subsequent day(s) and are provided for: • Inpatient services • Nursing homes • Rest homes • Assisted living • Home health visit code also available

23. Pulmonary Services: Spirometry • Pulmonary function testing that measures breathing mechanics • Code provided for before and after bronchodilator treatment • Code 94070: multiple increasing dosages of a treatment administered to determine the effects of treatment in increments

24. Allergy and Allergen Immunology • Immunotherapy is treatment • Codes provided for testing by: • Percutaneous • Intradermal • Patch • Inhalation • Ingestion • Professional services: three coding scenarios • Physician prepares and provides the antigen to the patient in a vial • Provider administers antigen (injection) • Physician both prepares and gives injections

25. Neurology:Sleep Studies (Polysomnography) • Sleep studies measure ventilation, respiratory effort, electrocardiogram (or heart rate), oxygen saturation • Polysomnography testing includes: • Electroencephalography (EEG) • Electro-oculography (EOG) • Electromyography (EMG) • Additional variables monitored for sleep staging include: • Airflow • Respiratory effort • Gas exchange • Limb muscle activity • Extended EEG • Penile tumescence • Gastroesophageal reflux • Continuous blood pressure monitoring

26. Neurology:EEG and EMG • Electroencephalography (EEG) • Records electrical activity in the brain • Recording time determines code • Used to determine brain death • Electromyography (EMG) • Records electrical activity in muscle(s) • 1–4 extremities • Larynx • Hemidiaphragm

27. Chemotherapy Administration • Services included in chemotherapy codes: • Local anesthesia • IV beginning and maintenance • Supplies • Preparation of chemotherapy agent(s) • Timing of services is important for correct administration code assignments. • 96413: assigned for the first hour • 96415: add-on code for each additional hour • Separate codes are reported for each method of administration • Incidental hydration administered with chemotherapy is not coded separately

28. Chemotherapy Administration • J codes – provided in HCPCS Level II for specific chemotherapeutic substances • If J codes are not accepted by the carrier, the supply code (99070) should be used with specification of agents received by the patient • Infusion pump • 96520: refill services code • 96414, 99211: continuous infusion for several days, including pump initiation and disconnection (with no refill)

29. Physical Medicine and Rehabilitation • Physical therapy, occupational therapy, and athletic training • Supervised modalities (reported one time per date), direct contact with provider is not required: • Application of hot or cold packs • Mechanical traction • Electrical stimulation • Vasopneumatic devices • Paraffin baths • Whirlpool • Diathermy • Infrared • Ultraviolet

30. Physical Medicine and Rehabilitation • Constant attention modalities – the provider cannot leave the patient (i.e., iontophoresis) • Codes represent 15 minutes of treatment time • Should not exceed increments of two per day • Therapeutic procedures • Given in 15-minute increments • Direct patient contact • Code 97150, assigned if two patients are being supervised at once • Medicare does not consider more than 1 hour of therapeutic services medically necessary

31. Physical Medicine and Rehabilitation • Training for activities of daily living (ADL) are coded in 15-minute increments. • Transfer techniques (on/off toilet) • In and out of shower or tub • In and out of bed to a chair • Meal preparation • Nutritional counseling • Ordered by a physician, provided by a registered dietitian • Timed in 15-minute increments

32. Physical Medicine and Rehabilitation:Acupuncture and Chiropractic • Acupuncture: needles are inserted under the skin • With or without electrical stimulation • Initial 15 minutes (only one “initial” code per session) • Each additional 15 minutes is coded with an add-on • Evaluation and management services reported separately with modifier -25 • Chiropractic manipulative services • Regions of the spine: Cervical, thoracic, lumbar, sacral, and pelvic • If manipulation is performed on more than one segment, count as one region adjusted

33. Education and Training for Patient Self-Management, Non-Face-to-Face Nonphysician Services, Special Services, Procedures, and Reports • Handling a specimen that is sent to an outside laboratory: 99000 • Miscellaneous codes include orthotics and prosthetics shipping for adjustments.

34. Education and Training for Patient Self-Management, Non-Face-to-Face Nonphysician Services, Special Services, Procedures, and Reports (cont’d) • Physicians may include codes for services provided after hours or on weekends or holidays. • 99058 may be added to the E/M code for service if a patient is seen emergently in the office • 99050 may be added if a patient is seen in the office on a weekend when normally closed