Jan 2008 Table of Contents

CODING & DOCUMENTATION



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Fam Pract Manag. 2008 Jan;15(1):43-44.

Diagnosis codes for PPD test

Q

What is the correct ICD-9 code for the purified protein derivative (PPD) skin test, CPT code 86580?

A

ICD-9 code V74.1 represents a special screening examination for pulmonary tuberculosis, including diagnostic skin testing for the disease. Often code V70.5, “Health examination of defined subpopulations,” may be a secondary diagnosis to indicate the test is performed as part of a pre-employment or occupational health examination. Additional ICD-9 codes may be reported to indicate the patient's risk for tuberculosis. For example, report V01.1 for “Contact with or exposure to tuberculosis,” 042 for HIV infection or 793.1 for “Nonspecific abnormal findings of radiological and other examination of the lung field.”

Remember that when a patient returns for the PPD reading, even when the reading is done by a nurse working incident to your services, you may report code 99211 for this evaluation and management (E/M) service.

Comparing E/M code usage

Q

I'm interested in how my E/M coding habits compare with other family physicians. How can I find out the breakdown for level-III and level-IV new patient office visits and established patient office visits?

A

The most current Medicare utilization data for family medicine indicates that 58 percent of established patient office visits were coded 99213 and 28 percent were coded 99214. Forty-three percent of new patient visits were coded 99203 and 27 percent were coded 99204. This data is available from the Centers for Medicare & Medicaid Web site at http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilization-forPartB.asp.

Other data sources include cost surveys such as those sold by the Medical Group Management Association (http://www.mgma.com). The Medicare contractor for your area may also provide regional utilization data.

It is important to periodically review the accuracy of your coding and documentation practices through internal or external chart review and compare the results to benchmarks such as these. For more information on how to track and analyze your coding patterns, see “How to Analyze Your E/M Coding Profile,” FPM, April 2007.

Denials for injury codes

Q

I have been getting denials from health plans when reporting diagnosis codes from the 900 series. For example, I received a denial for reporting CPT code 10120, “Incision and removal of foreign body, subcutaneous tissues; simple,” with ICD-9 code 915.6, “Superficial foreign body (splinter) without major open wound and without mention of infection.” I also received a denial for reporting office visit code 99213 with diagnosis code 922.31, “Contusion of the back.” What am I doing wrong?

A

You need to consult the adjustment reason codes on the remittance advice. If the reason for the denial is unclear, contact the payer for clarification. It is possible you are receiving denials because you are not completing the accident information in sections 10 and 14 of the claim form or not reporting E codes. This information indicates what happened to the patient, where it happened and under what circumstances. Payers need this information to determine liability for claims. For instance, an E code can identify how the patient with the contusion got it (e.g., E888.1 would indicate that the patient fell and hit the bath tub, or E849.0 would indicate that the contusion occurred at home). The more information you provide to the payer, the less likely that your claim's processing will be delayed while the payer seeks information from the patient.

Requirements for 99374

Q

I care for a quadriplegic patient who has 12-hour nursing care at home. I typically spend at least 15 minutes filling out forms and signing orders for him each month. I perform a house call once or twice a year. Is it appropriate to bill care plan oversight code 99374 for my administrative time?

A

It depends on the payer. For a patient under the care of Medicare-covered home health, report code G0181 when 30 minutes or more of your time is spent in care plan oversight activities during a calendar month. Other payers may pay for code 99374 for a patient who is under the care of a home health agency; it indicates that the physician spent 15 to 29 minutes in a calendar month on any of the following activities:

  • Development or revision of care plans;

  • Review of subsequent reports of patient status;

  • Review of related laboratory and other studies;

  • Communication (including telephone calls) for purposes of assessment or care decisions with health professionals, family members, surrogate decision makers (e.g., legal guardians) or key caregivers involved in the patient's care;

  • Integration of new information into the treatment plan or adjustment of medical therapy.

Your home visits are separately billable using a home services code (99341-99350). Also consider that where care plan oversight does not apply, home health certification or recertification might. See “An Update on Certifying Home Health Care,” FPM, May 2001, for more information on reporting these services.

Coding for cosmetic procedures

Q

I would like to incorporate cosmetic procedures into my practice but am uncertain how to code for them. What codes would I report for Botox and filler injections? What about sclerotherapy?

A

It may be advisable to provide these services on a cash-only basis. Payers will typically not reimburse for procedures unless they are medically necessary.

The codes for Botox injections (both cosmetic and medically necessary) are as follows:

  • 46505, Chemodenervation of internal anal sphincter;

  • 64612-64614, Chemodenervation of muscle(s) innervated by facial nerve, neck muscles, or extremities or trunk muscles;

  • 64650-64653, Chemodenervation of eccrine glands or other areas.

Report Botulinum toxins with code J0585, “Botulinum toxin, type A, per unit,” or J0587, “Botulinum toxin, type B, per 100 units.” For filler injections, see codes 11950-11954, “Subcutaneous injection of filling material,” or HCPCS code S0196, “Injectable poly-l-lactic acid, restorative implant, 1 mL, face (deep dermis, subcutaneous layers).” For sclerotherapy, see codes 36468-36471, “Single or multiple injections of sclerosing solutions, spider veins (telangiectasia).”

When reporting services provided for cosmetic reasons, consider ICD-9 codes in the V50 series, “Elective surgery for purposes other than remedying health states.”

Medicaid and G codes

Q

Should G codes only be used for reporting Medicare services? What codes should I report to Medicaid for care plan oversight?

A

Medicare often establishes G codes to differentiate its requirements from the requirements listed in CPT for similar services. Other payers may reimburse certain G codes (e.g., care plan oversight code G0181). Medicaid plans are administered on the state level, and each state may have different guidelines for coverage and coding of services. Check with your state Medicaid administrator for guidance on reporting care plan oversight services.

Instructions for inhaler use

Q

How should I bill for instructing patients on how to use an inhaler?

A

You should use code 94664, “Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device,” to report instruction to patients on the use of these devices. You or qualified medical staff (e.g., a medical assistant or nurse) working incident to your service may use this code.

Because some payers bundle code 94664 with E/M services provided on the same date, you should append modifier 25 to the E/M code to increase the chances that you will be paid for both services.

About the Author

Cindy Hughes is the AAFP's coding and compliance specialist and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel, which includes Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Emily Hill, PA-C; Kent Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.

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.

 

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

Copyright © 2008 by the American Academy of Family Physicians.
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