Consultation Codes are Back: CPT® 2014 Introduces 4 New Consultation Codes

Interestingly, four new codes have been added that describe the work of two medical professionals who discuss a patient’s condition over phone or Internet.

A few years ago, Medicare and other carriers stopped recognizing consultation codes. But all that is about to change as CPT® 2014 has added four new consultation codes with effect from January 1, 2014.
So from the first day of the New Year, if two medical professionals discuss a patient’s condition via phone or internet, you’ll report the following codes:

• 99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
• 99447 – … 11-20 minutes of medical consultative discussion and review
• 99448 – … 21-30 minutes of medical consultative discussion and review
• 99449 – … 31 minutes or more of medical consultative discussion and review.

These codes are more likely to be used for complex or urgent cases where the situation makes it difficult for the consultation to provide a face-to-face service, reads CPT® 2014 guidelines. For example, the consultant may be located far away.
Questions related to time
Coders need to be alert to:

• Why these codes are broken into time
• How that time will be measured (reading, discussing, interpreting, further research, etc.).
• How will the time be documented
• Will it be documented

Tips you’d like to make note of:

• For consultations less than 5 minutes, avoid using these codes
• Major part of the service time reported (more than half) must be devoted to the medical consultative verbal/Internet discussion.
  • The consult includes review of related medical records, path/lab studies, imaging, medications, and similar date.
  • A single code covers all contact time and review time, so add together and calculate the total time spent when multiple calls/internet contacts are performed for a single consult.

The earlier you’re up to speed on the 2014 CPT^® changes, such as the above-mentioned new codes for inter-professional consultations, the more likely for you to see fewer payment delays for those services. An online tool like SuperCoder’s Fast Coder can help you get 2014 CPT^® code details instantly – including new, revised, and deleted codes. The easy-to-use tool will help you get:

• Essential instructions from CPT® coding guidelines
• Upcoming and historical Info for the CPT® code(s) and/or keyword(s) entered
• The Coding Institute’s written simple explanations containing CPT® codes or keywords searched
• All personal notes for the CPT® code entered and all personal notes containing the code(s) and/or keyword(s) entered.
• And much more.

Append 76 for Multiple Nebulizer Treatments

Question: A patient with acute asthma requires three same-visit nebulizer treatments to control his asthma. Should I bill 94640 and J7613 multiple times, one time, or one time with a modifier for each additional treatment?

Washington Subscriber
Answer: When a patient receives multiple aerosol treatments on the same date, you should use 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the first treatment.

Catch: Subsequent treatments will require modifier 76 (Repeat procedure by same physician), according to CPT.

Therefore, you would code the example of three nebulizer treatments as:
 
 94640 - first treatment
 
 94640-76 x 2 - two subsequent treatments.

For the inhalation solution, you should report three units of J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg). Because J7613 represents one "unit dose," you should report per nebulizer treatment or, in your case, J7613 x 3. If the internist meets the criteria for reporting an E/M code, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient ...) as well.

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 

Water Down These Hydration/Injection NCCI 12.0 Edits

Hint: Look to modifier 25, not 59, to bypass E/M and injection edits
When your ob-gyn provides hydration or injection services, you should count that as part of the surgical procedure. The National Correct Coding Initiative (NCCI) version 12.0 strikes at the following new hydration and injection codes:

- C8950 -- Intravenous infusion for therapy/diagnosis; up to 1 hour

- C8951 -- -each additional hour

- 90760 -- Intravenous infusion, hydration; initial, up to 1 hour

- +90761 -- -each additional hour, up to 8 hours (list separately in addition to code for primary procedure)

- 90772 -- Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

- 90774 -- ... intravenous push, single or initial substance/drug

- +90775 -- -each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure).

In a nutshell: These new hydration and injection codes have been added to all surgical procedures. That means you shouldn't report the hydration, IV push or diagnostic injection separately from the surgery -- unless your documentation meets the criteria for supporting the use of a modifier (such as 59, Distinct procedural service).

Red flag: -With the addition of the new and renumbered injection codes, coders need to be aware that all of the E/M service levels have been bundled into each of them (such as, 90760-90775),- Witt says. This means that if you did not use an -approved- modifier to bypass the edit and bill both, payers would reimburse only the injection code, not the E/M service.

Keep in mind: You can use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bypass an NCCI edit anytime your ob-gyn performs a procedure as well as an E/M visit -- but this modifier goes only on the E/M code, Witt says. -This is why when NCCI bundled 99205 into 90772 and gave this edit a modifier indicator of 1, you can use modifier 25 on 99205 to bypass this edit.-

Medicare has indicated that although a physician may be able to make a case for billing the intramuscular injection code with a higher-level E/M service (it would have to be separate and significant from the injection), you should never bill both when the E/M level is only 99211. For this reason, the bundling indicator assigned to 99211 is -0.-

Here’s How to Report History of Chlamydia

What diagnosis code should I report for a history of Chlamydia?

You should report V13.29 (Personal history of other diseases; other genital system and obstetric disorders; other genital system and obstetric disorders) or V13.02 (Personal history, urinary [tract] infection), as Chlamydia can cause urinary tract infections. Be on the lookout: As neither of these codes is very informative, the ICD-9 staff will put this issue on the agenda for discussion at the next Coordination and Maintenance Committee meeting to perhaps develop a V code just for this. Keep watching The Ob-gyn Coding Alert  for the latest information. ICD-10: When ICD-9 becomes ICD-10 in 2013,you'll report Z87.49 (Personal history of other diseases of the genitourinary system) instead of V13.29 and Z87.41 (Personal history, urinary [tract] infection[s]) instead of V13.02.

Examine Ovary Along With Dermoid Cyst Removals

:What CPT code should I report for the removal of a dermoid cyst via a laparoscope?

You need to carefully read your ob-gyn's op and pathology report. You would report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) if the ob-gyn removed no part of the ovary with the cyst. On the other hand, you would report 58661 (... with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) if the ob-gyn removed part of the ovary along with the cyst.

58720: Make Use of Modifiers LT, RT

My ob-gyn performed an exploratory laparotomy, partial left salpingectomy, left oophorectomy, right ovarian cystectomy. I billed with 58720 and 58925-51, but the insurance company only paid for 58720. What did I do wrong?

You should have added modifier LT (Left side) to 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]) and modifier RT (Right side) to 58925 (Ovarian cystectomy, unilateral or bilateral). This lets the payer know your ob-gyn performed these procedures on two different sides.The Correct Coding Initiative (CCI) does not bundle these codes, but notice how 58720's descriptor does include "separate procedure." This might have caused payer problems.Also, you should have billed 58925 first, because it has higher relative value units (RVUs) than 58720.

Don't Lose Sleep Over Medicare's New 99211 Rule

Why you'll now get paid for both 90780 and an E/M

Although you can expect your reimbursement to increase now that Medicare will pay for 99211 in addition to drug administration codes (90780-90788), make sure you code with caution -- CMS still will not let you report the codes together.

In the 2004 Medicare Physician Fee Schedule, which took effect Jan. 1, CMS adds 0.17 relative value units (RVUs) to therapeutic infusion and injection codes 90780-90788. The RVU increase equals the RVUs for E/M code 99211 (Office or other outpatient visit for the E/M of an established patient ...). Therefore, Medicare considers 99211 included in the codes when you bill them on the same day.
Pick Up an Extra $21
Because infusion and injection codes (90780-90788) now include the same RVUs as 99211, you will get paid for an infusion or injection and E/M service every time you report 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) or 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

The bottom line: You'll now pick up the national average of $21 that 99211 pays when you submit codes 90780-90788.

Previously, most allergy practices didn't bill 99211 on the same day as 90780-90788 because Medicare considers the E/M service included in the procedures.

"I cannot think of a situation in which there would be a significantly separate service that would be provided by a nurse during the administration of an injection or infusion," says Bruce Rappoport, MD, CPC, who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

Watch Out for Modifier -25
In the rare case that a practice bills for 90780-90788 in addition to a higher-level office visit (for example, 99212), coders should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, according to CMS transmittal 34, dated Dec. 24, 2003.

Red flag: Remember that you can bill only a physician's service, not the nurse's, with a 99212 or higher, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla. Also, Medicare would most likely pay only for the E/M code, not the infusion or injection code.