Coding FAQs-Ambulatory Lynn M. Myers MD, CPC, CHC
Ambulatory FAQs What is Modifier -25? Allows reimbursement for both the office visit and (unplanned) procedures, like injections, nebulizer treatments, ECGs, etc Mark when office visit AND the procedure are done at the same encounter Applies to any procedures during an office visit encounter except lab and Xray (ECGs, nebulizer treatment, injections, vaccines, laceration repairs in certain circumstances)
Ambulatory FAQs What is ‘Incident-to’? Applies to traditional Medicare only Allows for services of midlevel practitioner to be reimbursed at physician rates Requires a physician presence in the office suite Applies to encounters that are following up on plans of care that were established by the physician
Ambulatory FAQs How do I code for procedures at the time of an office visit? Code the office visit according to services provided (and documented with History, PE and Medical Decision Making), and use modifier 25 to indicate that an unplanned procedure was performed The procedure is coded with the pertinent diagnosis code.
Ambulatory FAQs What’s the difference between a simple and a complex abscess procedure? • 10060 I&D of simple or single abscess • 10061 I&D of complicated or multiple Was it a simple puncture and drain, or was a wick or drain placed? Was there more than one abscess?
Ambulatory FAQs How do I code for Trigger Point Injections? • 20550 Single tendon sheath injection-i.e. plantar fascia • 20552 One or two trigger point injections in the muscle • 20553 Three or more trigger point injections in the muscle Report the J code for the medicine injected J1094 Decadron J3301 Kenalog Report the surgical tray A4550 Document the method of localizing the site, the location and the number of injections performed.
Ambulatory FAQs How do I code for joint injections? • 20600 Small joint (fingers, toes) • 20605 Medium joint (ankle, elbow, wrist) • 20610 Large joint (shoulder, knee, hip) Report the J code for the medication used Report the surgical tray A4550 Document the methodology for localizing the injection site and the anatomic site injected and the technique utilized. If the patient presents for knee pain and after evaluation it is determined that a knee injection is appropriate, an office visit may be reported at the same encounter (with modifier 25). For a subsequent injection for the same diagnosis, an office visit charge is not appropriate.
Ambulatory FAQs How do I code for joint aspirations? Use the same code as for joint injections • 20600 small joints • 20605 medium joints • 20610 large joints Because it is an aspiration, no drug code is reported. For FlowCast providers the modifier ND is reported to indicate that no drug was administered. Document a Procedure Note!
Ambulatory FAQs How do I code the right amount of an injected drug? Kenalog is priced in 10mg units, but is supplied in 40mg/cc or 80mg/cc. If 40 mg is given, report 4 units Decadron (dex phosphate, not the LA) is priced per 1mg, but is supplied in 4mg/cc or 8mg/cc. If 8 mg is given, report 8 units Rocephin is priced per 250mg, but is supplied in 250mg/cc or 500mg/cc. If 1000mg is given, report 4 units of the 250mg/cc or 2 units of the 500mg/cc Celestone is priced per 4mg, but supplied in 6mg/cc If 12 mg is given, report 3 units
Ambulatory FAQs How do I code immunizations? For age <19 with counseling, use 90460 and 90461 • 90460 is for the each vaccine, any route, and the first component • 90461 is for all remaining components • If MMR and DTaP are administered to a 2 year old • 90460 x2 (coded for each vaccine and first component of each one) • 90461 x4 (coded for the additional 4 components) • If Pentacel is administered, • 90460 x1 (Coded for the vaccine and the first component • 90461 x 4 (coded for the remaining 4 components) For age 19 and older, or if <18 and no counseling is performed, use administration codes 90471, 90472, 90473 and 90474 • 90471 is for the first injectable vaccine • 90472 is for the second injectable vaccine, with units if more than 2 are given • 90473 and 90474 are used for nasal vaccines Always report the vaccine code AND the administration code-
Ambulatory FAQs How do I report therapeutic injections? Report administration code 96372 for subcutaneous or IM injections Report the J code for the drug given
Ambulatory FAQs What about time-based coding? Document total time AND time spent counseling Itemize the discussion details Utilize the level of service code that corresponds to time spent for a ‘typical’ encounter: 99213-15 minutes 99214-25 minutes 99215-40 minutes Prolonged time 99354 may be reported in addition to the level of service, if the ‘typical’ time is exceeded by more than 30 minutes. 99213-45+ minutes 99214-60+ minutes 99215-70+ minutes Documentation must include the total time spent in the encounter, the key components of the sick visit, and the details of the additional time spent.
Ambulatory FAQs What constitutes ‘Malnutrition’ 263.X? 10% unintentional weight loss in 6-12 months Albumin <3.4 BMI <18.5, especially with comorbidity Poor nutrition or loss of appetite Muscle wasting 263.9 Unspecified protein-calorie malnutrition 263.2 Arrested development following protein-calorie malnutrition 263.0 Malnutrition of moderate degree 263.1 Malnutrition of mild degree 263.8 Other protein-calorie malnutrition
Ambulatory FAQs What about Smoking Cessation? Commercial plans in Texas may not pay Medicare pays for 2 attempts per year, with 4 encounters per attempt For smokers without underlying disease due to smoking, report G0436 (3-10 minutes) or G0437 (more than 10 minutes) and document time spent in counseling. There is no deductible for this code. For smokers with underlying disease (COPD, PVD), report 99406 (3-10 minutes) or 99407 (more than 10 minutes).