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.

ICD-9 & CPT code for feeding difficulty

You should bill (99211-99215, Office or other outpatient visit for the E/M of an established patient, usually the presenting problem[s] are minimal;

Watch out: If your group had not previously treated the infant in any location, you would use the new patient office visit codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …).

Link the office visit code to the infant’s problem(s). Some applicable ICD-9 codes you can report for the baby include:
-------------------------------------------------------------------------------------------------------------------
Pediatric Coding Corner: 4 Tips Ensure Success in Coding Feeding Problems for 2010
Use expanded 779.3x to describe newborn issues.
Brings an expanded 779.3x (Feeding problems in newborn).

• 779.31 (Feeding problems in newborn): Feeding problems can be broadly categorized as underfeeding and overfeeding. Underfeeding results from the infant’s failure to take sufficient amounts of milk. Oftentimes, family physicians spot this problem when there is a failure to gain weight appropriate for their age or when the mother notices that their infant suckles infrequently or for only short periods of time. Overfeeding results from supplemental foods and therefore is not a problem in the perinatal period.

• 779.32 (Bilious vomiting in newborn): Bilious vomiting is vomiting of gastric contents containing bile, often described as greenish vomitus.

• 779.33 (Other vomiting in newborn): Vomiting is the complete emptying of the stomach contents often occurring after feeding.

• 779.34 (Failure to thrive in newborn): This occurs when an infant’s physical growth as measured by his weight and height is significantly below the average for his age group.

Most of these conditions were previously lumped under 779.3. These changes make the coder’s job much easier. “The more specific the codes, the better for all,” says Gwenn S. O’Keeffe, MD, CEO and founder of

Incorporating these new codes into your practice will be a breeze with four easy tips:

1: Use 779.31, 779.34 for Follow-Up Visit Problems
Remember that follow-up visits after a hospital discharge are not necessarily well visits. After a newborn has been discharged from the hospital, “we always do a two- to three-day follow-up visit,” notes Charles Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey.

Family physicians make use of this visit to evaluate the presence of any problems a newborn may have, and commonly, this will include feeding problems. For example, during a visit, the mother relays to the FP that her infant seems to have difficulty latching onto her nipple. Code 779.31. Likely in this case, the FP will spot low birth weight gains. Therefore, also code 779.34.

2: Distinguish Between Regurgitation, Vomiting

Regurgitation means retuning small amounts of swallowed milk shortly after or while feeding. Compare this to vomiting, which is the complete emptying of stomach contents. Although regurgitation is a natural occurrence during the first months of life, it often makes new parents worry.
Example: During an office visit, a mother tells the FP that she is worried when she notices small amounts of milk coming from her infant’s mouth after feeding. There is no specific code for regurgitation in the ICD-9-CM.
In the ICD-9-CM 2009 index to diseases, the listing for “regurgitation” leads to the code for vomiting alone (787.03). Using the new 2010 codes, here are three possible scenarios:
1.If the FP documents the mother’s observation as newborn vomiting, consider coding it as 779.33 in 2010.
2.Use 779.31 if documentation indicates it’s a feeding problem.
3.If the FP otherwise considers it a normal part of being a newborn, then no code is necessary.
3: Reserve 799.34 for Newborn Period
ICD-9 codes 760-779 are for conditions which have their origins in the perinatal period only, which occurs before birth through the first 28 days after. Look to codes outside this section for similar conditions for older patients.
Example: An FP notes that a 1-month-old (30 days) infant has low weight gain. On evaluation, the FP finds the infant to be below the normal average weight for his age.
The FP diagnoses failure to thrive.
In this case, 783.41 would be the appropriate code. Code 779.34 is for newborns 28 days old or younger.
4: Code for the Specific Disease if Applicable
When the FP specifies obstruction as a diagnosis, there may be no need to use 779.32. Bilious vomiting is inherently a part of intestinal obstruction and is the hallmark sign of the presence of intestinal obstruction.
Example: Three days after delivery, a newborn had vomiting of greenish gastric secretions and was feeding poorly. The FP who evaluates her gives a diagnosis of intestinal obstruction. Code this as:
• 751.1 -- Atresia and stenosis of small intestine
• 779.31 -- feeding problems in newborn.

What CPT code would i use for an excisional biopsy of a duputyren band on the finger?

Watch your surgeon's documentation for clues regarding partial or complete treatment and the number of digits involved, and you'll be on your way to clean Dupuytren contracture release claims every time.

What happens: Dupuytren contracture release involves excising contracted fibrotic bands of the palmar fascia. Surgeons can either use a standard open incision with fasciectomy (known as the McCash technique) or percutaneous fasciotomy (known as the Luck technique). Here's how to break down these techniques into coding realities.

Fasciotomy Can be Open or Percutaneous
If the surgeon completes fasciotomy to treat Dupuytren's contracture (728.6, Contracture of palmar fascia), check the operative notes for whether he used an open or percutaneous approach. Then, choose between 26040 (Fasciotomy, palmar [e.g., Dupuytren's contracture]; percutaneous) or 26045 (... open, partial) and report the correct code for each finger the surgeon treats.

Extra codes: Your orthopedist can perform percutaneous or minimally invasive treatment of Dupuytren's contracture in an office setting, which means you'll need to report additional codes. Report 26040 for the procedure, along with the appropriate E/M choice. Because of the work involved, your most likely options are 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

The most common type of percutaneous treatment is needle aponeurotomy, or NA. The physician uses the tip of a hypodermic needle as a very small knife to divide the contracting cords of Dupuytren's disease.

Count Digits With Fasciectomy
Your surgeon might opt for fasciectomy to treat more extensive cases of Dupuytren's contracture. Base your codes on whether he completes a palm-only procedure or also accesses the digits:
26121 -- Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)

26123 -- Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft).

When reporting 26123, append +26125 (... each additional digit [List separately in addition to code for primary procedure]) as needed. Code "26125 is an add-on code required to identify each additional digit," CPT directs you to report +26125 with 26123. Because 26121 applies to palm-only procedures, you don't need codes specifically for digits.

Tip: When coding these cases, you're looking at "otomy" versus "ectomy. "If coders will watch for the wording, they'll know which codes to use.