CODING & DOCUMENTATION
Answers to Your Questions
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Fam Pract Manag. 2004 Oct;11(9):25-26.
- CPT’s pharmacologic management code
- ECG code for symptomatic patients
- Biopsy code 11100
- Cryotherapy for multiple warts
- Failed venipuncture
- CPT codes for wound care
- Reporting INR
- Trigger-point injection codes
- ICD-9 code for a TB test
CPT’s pharmacologic management code
A local billing and coding expert told us that only psychiatrists, psychiatric APRNs or those who are enrolled in a psychiatric insurance carve-out (usually behavioral health) can submit CPT code 90862, “Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.” He said that family physicians and other physicians are restricted to the evaluation and management (E/M) visit codes. Does CPT make this restriction?
No. In fact, CPT states that “it is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.”
So, from a CPT perspective, family physicians can submit code 90862. Whether they will get reimbursed for it depends on a health plan’s payment policy. Some health plans may use mental health and behavioral health carve-outs that preclude payment for 90862 except when billed by a psychiatrist or other designated mental health professional such as a psychiatric APRN, as your coding expert described. This effectively limits the use of this code to those specialties, despite the language in CPT quoted above.
For more information on the proper use of code 90862, see “Pharmacologic management,” FPM, May 2003, page 17.
ECG code for symptomatic patients
When I do an electrocardiogram (ECG) for a patient presenting with a symptomatic illness (e.g., chest pain, dizziness and diaphoresis), what ECG code should I submit? I have been told that CPT code 93000 is only for a “routine” ECG and, therefore, not appropriate in this case. However, I have reviewed CPT’s cardiography codes (93000-93278), and I could not locate a more appropriate code than 93000, “Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report,” tagged with the stated primary symptomatic illness. Am I missing something?
I don’t think so. I agree that 93000 tagged with the stated primary symptomatic illness appears to be the most appropriate way to code the service you’ve described. “Routine” in the descriptor refers to the performance of the ECG (i.e., this ECG is more routine than rhythm strips, stress ECGs, Ergonovine provocation and microvolt T-wave alternans) rather than the condition of the patient, so the code should still be valid with symptomatic patients. Also, I am not aware of any other code that Medicare or other payers would direct you to use in this situation. In fact, Medicare reimbursed code 93000 almost 10 million times in 2001, which would not be the case if the code was not to be used with symptomatic patients.
Biopsy code 11100
Does the term “biopsy” in the descriptor for CPT code 11100, “Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion,” mean that the code only applies to a partial lesion removal as opposed to a full excision?
“Biopsy” in the context of 11100 does generally mean less than a full excision. However, in some cases, 11100 can be used even when the biopsy procedure results in the removal of the entire lesion. It depends on the intent of the procedure. If the intent is to identify the lesion and/or determine whether additional treatment is necessary, code 11100 would be appropriate, regardless of whether the lesion is completely or partially removed. If the intent is to remove the lesion, an excision or shave-removal code would be appropriate.
Cryotherapy for multiple warts
If I perform cryotherapy on three warts, I know I should submit 17000, “Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion,” once for the first lesion and 17003, “... second through 14 lesions, each (List separately in addition to code for first lesion),” with 2 units of service for the other lesions. But do I also need to attach modifier -59, “Distinct procedural service,” or modifier -51, “Multiple procedures,” to 17003?
No, you do not need to attach a modifier to 17003. Since the descriptor for 17003 indicates that these are separate lesions, modifier -59 is not necessary. Further, 17003 is a designated add-on code, which means that it is “exempt from the multiple-procedure concept,” according to CPT. Note that destruction of flat warts should be coded with 17110 or 17111 instead.
If I attempt to start an IV for blood collection in the office (e.g., on an infant suspected of sepsis) but, after several attempts, abort the effort and send the patient to the hospital for admission, what code(s) should I submit for the failed attempts?
You should submit the appropriate IV or venipuncture code (e.g., 36400, “Venipuncture, under age 3 years, necessitating physician’s skill, not to be used for routine venipuncture; femoral or jugular vein”) with modifier -52, “Reduced services,” attached. This modifier indicates that the service was reduced or eliminated at the physician’s discretion.
CPT codes for wound care
Which CPT codes should I use for wound care: 11040-11044 or 97601-97602?
CPT’s debridement codes 11040-11044 are the most appropriate codes to use when the service is provided by a physician. Codes 97601 and 97602 do describe active wound care management, which involves procedures “to promote healing, and involve selective and nonselective debridement techniques,” but they are generally intended to be reported by nonphysician professionals (e.g., wound care nurses and physical therapists), according to CPT Changes 2001: An Insider’s View. If a nonphysician provider does provide the service, note that 97602 is not separately reimbursable by Medicare, which considers the service to be “bundled” with other reimbursable services.
I was informed by our lab that the international normalized ratio (INR) is a calculation of a patient’s prothrombin time ratio and, therefore, does not have a corresponding CPT code. Is that right?
Yes. The INR is the ratio of the patient’s prothrombin time to a control prothrombin time multiplied by the international sensitivity index, and there is no specific CPT code for reporting it. Instead, INR calculation is considered part of the prothrombin time testing code, 85610. Note that there are three HCPCS codes (G0248-G0250) related to home INR monitoring for patients with mechanical heart valve(s) who meet other specific Medicare coverage criteria. These codes can be used to report the provision of test materials, the training of a patient and the review of patient use of INR home-testing equipment.
Trigger-point injection codes
Can we use the trigger-point injection codes (20552 and 20553) for “dry needle” trigger-point injections – those that do not contain an injectable?
Yes. The intent of CPT codes 20552 and 20553 is to identify the procedure of performing the trigger-point injection, regardless of whether an injectable is supplied. If an injectable is supplied, you would need to report the supply of any injectables separately by submitting the appropriate HCPCS code(s) or code 99070, “Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).” Note that 20552 and 20553 should not be used for acupuncture procedures, which are more appropriately reported with CPT codes 97780-97781.
ICD-9 code for a TB test
When I submit 99211 for reading a TB skin test, which ICD-9 code should I submit with it?
You should submit V74.1, “Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis,” if the test is negative, or 795.5, “Nonspecific reaction to tuberculin skin test without active tuberculosis,” if the test is positive.
For more on coding TB skin tests, see “Tuberculosis skin tests,” FPM, September 2003, page 25.
Kent Moore is the AAFP’s manager for health care financial and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.
Conflicts of interest: none reported.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most detailed and up-to-date information.
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Copyright © 2004 by the American Academy of Family Physicians.
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