CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2005 Feb;12(2):23-24.
- Care plan oversight for Medicare patients
- ICD-9 code for prescription drug management
- Work RVUs for ob ultrasound
- Coding cerumen removal
- Newborn-care codes
- Telephone care
- Coding visits to care facilities
- HCPCS code for Depo-Testosterone
- Deep excision of a lipoma
Care plan oversight for Medicare patients
I supervised the terminal care provided to a Medicare patient by home-health nurses and submitted 99375, “Physician supervision of a patient under care of home health agency …; 30 minutes or more,” for my time, but Medicare denied the service. Should I have used a different code?
CPT code 99375 does accurately describe the care you provided, but Medicare does not recognize this code. Instead, you should submit G0181, “Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more,” when you provide this service to Medicare patients (or G0182 if the patient is under a Medicare-approved hospice).
ICD-9 code for prescription drug management
Is there an ICD-9 code for an office visit that only involves prescription drug management?
Yes. Code V58.53 describes an encounter for therapeutic drug monitoring, where “drug monitoring” refers to the measurement of the level of a specific drug in the body or the measurement of a specific function to assess the effectiveness of a drug. If the prescription drugs you are managing represent long-term (current) drug use (e.g., for Coumadin treatment) you should use an additional code in the series V58.61–V58.69. However, if none of these V codes is appropriate, you can just report the ICD-9 code for the underlying condition that requires the prescription drug.
Work RVUs for ob ultrasound
Since we've started tracking physician productivity in our practice with relative value units (RVUs), we've discovered that the work RVUs for ob ultrasounds are quite low for the amount of work and expertise required. For example, 0.99 work RVUs are allowed for the most common procedures, 76801, “Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks, 0 days), transabdominal approach; single or first gestation,” and 76805, “Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation.” This is compared to the more than 3 work RVUs assigned to colonoscopies, which require the same amount of time. Do the work RVUs associated with ob ultrasounds refer only to interpreting the ultrasound and not also to performing it?
Yes. The work RVUs assigned to the ob ultrasound codes (76801–76817) represent only the professional component of the service (the physician interpretation and report). The technical component (the actual performance of the ultrasound) is captured principally through the practice-expense RVUs. If a physician, rather than a technician, is doing the ultrasound, you may want to credit the physician with the practice-expense RVUs in addition to the work RVUs. In the case of 76801, this would be 3.44 RVUs (0.99 work RVUs and 2.45 practice-expense RVUs), which would be comparable to the 3.69 work RVUs for a diagnostic colonoscopy (code 45378).
Coding cerumen removal
Recently, I was told that the appropriate use of CPT code 69210, “Removal impacted cerumen (separate procedure), one or both ears,” requires direct visualization by the physician and removal using suction, a cerumen spoon or delicate forceps. However, my understanding of 69210 has always been more liberal than this, including removal using irrigation or chemical solvents that may be done by a physician or by ancillary staff incident-to a physician's service. Which is the correct interpretation of this code?
It depends on the payer. Because CPT does not specify what the term “removal” refers to with this code, removal by any means would qualify from a CPT perspective. Assuming Medicare's “incident-to” rules are met, you should also be able to code this as incident-to a physician's service in some cases. (For more information on “incident-to” reimbursement, see “The Ins and Outs of “Incident-To” Reimbursement,” FPM, November/December 2001, page 23.)
However, according to CMS, payment for cerumen removal is made only when the following criteria are met:
1. The service is the sole reason for the patient encounter;
2. The service is personally performed by a physician or non-physician (NP, PA, CNS);
3. The service is provided to a patient who is symptomatic;
4. The documentation illustrates significant time and effort spent performing the service.
CMS also defines routine cerumen removal as the use of softening drops, cotton swaps and/or cerumen spoon and is not paid separately since it is considered incidental to the office visit.
These criteria may also be true for some commercial payers. Check with your individual payers to determine their policies.
For newborn care provided in the hospital, when should the newborn-care codes (99431–99435) be used and when should the initial and subsequent hospital care codes (99221–99233) be used?
The newborn-care codes are generally used for healthy newborns, which is why the descriptors reference a “normal” newborn (e.g., 99431, “History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (This code should also be used for birthing room deliveries)”). Initial and subsequent hospital care codes should be used instead of the newborn-care codes when the newborn is ill (but not critically ill). If the newborn is critically ill, you should consider using the inpatient neonatal critical care codes 99295 and 99296.
What code(s) should I submit for telephone discussion or treatment I have with patients after seeing them face-to-face initially?
According to CPT, you should submit codes 99371–99373 for the types of telephone calls you've described. Some, but not all, payers will reimburse you for these codes, and among those who don't, some may allow you to collect from the patient for the “noncovered” service. However, Medicare and many other payers consider telephone calls to be “bundled” services, which means they will not separately reimburse you for them or allow you to collect from the patient for them (since the payer considers payment for these codes to be included in the payment made for other services you provide, such as office visits). You will need to check each of your health plan contracts to see which plans fall into which category.
Coding visits to care facilities
What CPT codes should I submit for routine medical visits at a rural handicapped facility for profoundly mentally challenged residents?
It depends on the exact nature of the facility. If the facility qualifies as a nursing facility (such as an intermediate care facility for the intellectually disabled), you should use the subsequent nursing-facility codes (99311–99313). Alternatively, if the facility is more akin to an assisted-living or custodial-care facility or a group home, you should use the domiciliary-care codes (99321–99333). Note that these codes have documentation requirements that must be met to support the billing level.
HCPCS code for Depo-Testosterone
What HCPCS code should I submit for Depo-Testosterone? We have been submitting J1060 and getting denied.
For Depo-Testosterone, you should submit either J1070, “Injection, testosterone cypionate, up to 100 mg,” or J1080, “Injection, testosterone cypionate, 1 cc, 200 mg.”
Code J1060, “Injection, testosterone cypionate and estradiol cypionate, up to 1 ml,” is used for such things as Depo-Testadiol or Andro/Fem.
Deep excision of a lipoma
What code should I submit for deep excision of a lipoma underneath the scalp?
Lipomas are typically benign tumors commonly found in superficial tissue. Accordingly, one of the codes for excision of a benign skin lesion of the scalp (11420–11426) would be most appropriate in your case. If a layered closure is required, you should also report the appropriate intermediate repair code (12031–12037).
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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Send questions and comments to email@example.com, 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 © 2005 by the American Academy of Family Physicians.
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