ED Coding and Reimbursement Alert

Learn more about these changes to prolonged care, flu vaccines, and Appendix G assignments.

ED coders can expect to make adjustments to chest procedure and observation care coding, as well as other services in 2013. Read on for analysis and commentary on the top changes you'll need to make.

Overview: The 2013 CPT® book was released earlier than usual this year, and includes 251 revised and 151 new Category I codes. There are also 100 codes that have been deleted.

Focus On Observation Changes

Nearly every E/M code has some revision, although the vast majority are for internal consistency with CPT's introductory language acknowledging that not every provider is a physician, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA. There is new language for 2013 in each of the E/M codes, which eliminates the word "provider" and replaces it with "qualified healthcare providers." Here is what it looks like for the ED E/M codes, using 99283 as an example.

• 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

An expanded problem focused history;
An expanded problem focused examination; and
Medical decision making of moderate complexity.

• Counseling and/or coordination of care with other physicians, providers qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
• Usually, the presenting problem(s) are of moderate severity.

Similar language appears in the observation codes, with a second change to remove the word "physicians: from the typical time statement.

• 99218 Initial observation of low complexity medical decision making
• Counseling and/or coordination of care with other physicians, other providers qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
• Usually the problem(s) requiring admission to "observation status" are of low severity. Physicians typically spend Typically 30 minutes are spent at the bedside and on the patient's hospital floor or unit.

Note Typical Times for the Same Day Admit and Discharge Observation Codes

The observation same day admit and discharge codes have similar wording changes, but also new for 2013, there are typical times listed in the code descriptors.

• 99234 Observation or inpatient hospital care with medical decision making that is straightforward or of low complexity
• Usually the problem(s) requiring admission are of low severity. Typically 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

Similar typical times now appear for 99235 and 99236

• 99235 ...Usually the problem(s) requiring admission are of moderate severity. Typically 50 minutes are spent at the bedside and on the patient's hospital floor or unit.
• 99236 ...Usually the problem(s) requiring admission are of high severity. Typically 55 minutes are spent at the bedside and on the patient's hospital floor or unit.

Use 99234-99236 With Prolonged Services Codes

The parenthetical note following the prolonged services code descriptor now includes 99234-99236 because with the addition of typical times to the code descriptor, it is possible to quantify when the typical time has been exceed justifying prolonged care, says Granovsky.

• 99356 Prolonged services in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)
• (Use 99356 in conjunction with 99218-99220, 99221-99223, 99224-99226, 99231-99233, 99234-99236, 99251-99255, 99304-99310, 90822, 90829)

Don't Count Two Way Radio Communications as Pediatric Critical Care

If you work in a pediatric ED, you might want to make note of this language change as well for pediatric critical care transport.

The non-face-to-face direction of emergency care to a patient's transporting staff by a physician located in a hospital or other facility by two-way communication is not considered direct face-to-face care and should not be reported with 99466 and 99467.

• 99466 -- Critical care face-to-face services delivered by a physician, face-to-face, during an Interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport
• 99467 -- ... each additional 30 minutes (List separately in addition to primary service)

Physician directed non face-to-face emergency care through outside voice communication to transporting staff should be reported using 99288 (Physician direction of emergency medical systems [EMS] emergency care, advanced life support) or 99485and 99486 based upon age and clinical condition of the patient.

Map in New Codes for Coordination, Transfer of Care

The E/M section contains new E/M codes for coordination of complex care (99487 -- 99489) and transitional care management services (99495 ��" 99496). These codes are the result of a special CPT® Workgroup tasked with finding a way to capture the additional work associated with these tasks above and beyond what would typically be covered in the post service work of another E/M code such as an inpatient hospital visit. These codes were expedited through the CPT® process to be ready for 2013 usage, says Granovsky.

Complex Chronic Coordination of Care Services

The new complex coordination of care codes describe patient management and support services to an individual that require clinical staff to implement a care plan involving multiple disciplines, which are directed by the physician or other qualified healthcare professional. The reporting provider oversees the management and or coordination of needed services for all medical conditions, psychosocial needs and activities of daily living. The typical patient for these coordination codes would have multiple chronic conditions expected to last for the foreseeable future and that place the patient at significant risk of death or decline. Examples would be patients suffering from multiple co-morbities such as dementia, chronic obstructive pulmonary disease or diabetes that complicate their care, says Granovsky.

Codes 99487-99489 are reported only once per calendar month and include all non-face-to-face complex chronic are coordination services and none or one face-to-face office or other outpatient visit. Only one physician or other qualified health care professional a can report the code for a particular patient during the calendar month, he adds.

Code 99487 is reported when there is no face-to-face visit with the physician during the month and at least 31 minutes of clinical staff time in coordination of care activities. The clinical staff time clock can not include any time spent on the date the physician is reporting another E/M service.

Code 99488 is reported when there is a face-to-face visit with the physician or other qualified health care professional during the month and there is at least 31 minutes of clinical staff time in coordination of care services.

Can Emergency Physicians Use These Codes?

Although emergency physicians do provide some oversight of complex chronic coordination of care and CPT® does not specify which medical specialties are allowed to report these codes; it seems unlikely the emergency physician will meet the qualifications as outlined in the preamble for this section. The requirement for supervising the staff that performs the care coordination functions would not be typical outside the ED setting, says Granovsky.

See Time Thresholds in Transitional Care Management Services Language

The new codes for transitional care management services (TCM), 99495and 99496, are for established patients whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting or observation status to the patient's community setting, be that home, nursing home or assisted living.

TCM starts on the date of discharge and continues for the next 29 days. It includes one face-to ��"face visit within the specified time frames, in combination with non-face-to-face services that may be performed by the physician or licensed health care profession or clinical staff under their direction. Additional E/M services after the first face-to face may be reported separately, but the first one is included in TMC code, says Granovsky.

The factors that determine which TMC code to report are medical decision making and the date of the first face-to-face visit. For the moderate complexity MDM code 99495, the face to face visit must occur within fourteen days and the higher complexity code 99496 requires the face-to-face visit within seven calendar days. It is the medical decision making over the service period reported that determines which level you should choose. Only one individual can report TMC and only once per patient within 30 days of discharge, Granovsky warns.

Watch Those Definitions of Days

Be sure to note that the requirement for communication with the patient or caregiver is two business days (Monday through Friday) except holidays without respect to normal practice hours, but the requirement for the face��"to-face visit is in calendar days. CPT® allows that if two or more separate attempts are made in a timely manner, but are unsuccessful and other transitional care management criteria are met, the service may still be reported, says Granovsky.

Similar to the complex chronic care coordination services, although emergency physicians perform some transition of care serivce3, they would not typically be eligible to report these codes.

Look to These Major Chest Drainage Procedure Code Revisions

In CPT® 2013, we see a reorganization of the codes used to describe chest drainage procedures with some prior codes being deleted and replaced with new codes.

Codes 32420, 32421, and 32422 have been deleted.

• 32420 -- Pneumocentesis, puncture of lung for aspiration
• 32421 -- Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent
• 32422 -- Thoracentesis, with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure)

To report those services you should now use one of the four new codes thoracentesis codes

• 32554 -- Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance
• 32555 -- ...with imaging guidance
• 32556 -- Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance
• 32557 -- ...with imaging guidance

Coding example: Consider this case: A 72-year-old male with a known history of lung cancer presents to the ED with increasing dyspnea. Chest X ray reveals a large left pleural effusion. The ED physician inserts a needle and drains the pleural effusion and the patient becomes more comfortable. No mention is made of imaging guidance. While in 2012 this procedure would have been reported with 32421, the correct coding as of date of service Jan. 1 2013 will be 32554.

Add New Appendix G Assignments For ED Procedures

Code 32551, tube thoracotomy has new descriptor language.

q 32551 -- Tube thoracostomy, includes includes water seal connection to drainage system (e.g., for abscess, hemothorax, empyema water seal), when performed, open (separate procedure)

Remember: The target symbol q means it is an Appendix G code with moderate sedation bundled into the value and not separately reportable unless specific requirements are met. Moderate sedation may be reported in addition to an Appendix G code if the procedure is performed in a facility setting and a second provider is involved. CPT® states, "In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in Appendix G, the second physician can report 99148-99150." CPT® codes 36010 and 36140 now appear in Appendix G.

Discern Other Qualified Health Care Professional Language Venipuncture Codes

Venipuncture codes now include the "other qualified health care provider" language.

• 36400 -- Venipuncture, younger than age 3 years, necessitating physician'sthe skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein
• 36410 -- Venipuncture, age 3 years or older, necessitating physician's the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Watch For Imaging Guidance Not Included In The Code Descriptor

In the introduction to the Radiology Section of CPT®, we see new wording for Supervision and Interpretation direction. It warns coders to check the code descriptors carefully to see if the surgical procedure under consideration contains imaging guidance or not. If it does, the imaging can't be separately reported. However, if there is no mention of imaging guidance in a code from the Medicine section of CPT®, radiological supervision and interpretation may be reported for the portion of the service that requires imaging. Remember that both services require image documentation, and the radiological supervision, interpretation and report, says Granovsky.

Also, look for an increase in the number of views required for cervical spine x-rays.

• 72040 -- Radiologic examination, spine, cervical; 2 or 3 views or less
• 72050 -- ... minimum of 4 or 5 views
• 72052 -- ... complete, including oblique and flexion and /or extension studies 6 or more views

We see the "other qualified healthcare professional" language appearing in the radiology section as well as the E/M section. For example:

• 76000 -- Fluoroscopy (separate procedure), up to one hour physician or other qualified health care professional time Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)

Just in Time For Flu Season, Prep for New Influenza Codes

There is a new code for influenza vaccine

• 90653 -- Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use

You will recall that he lightening symbol in CPT® means FDA approval pending

Other influenza codes 90655-90660 influenza have been revised by adding the word "trivalent" in the code descriptor. For example:

• 90655 -- Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

And another new code influenza appears at the end of that code sequence:

• 90672 -- Influenza virus vaccine, quadrivalent, live, for intranasal use

A new parenthetical direction appears in the cardiography section of CPT®. In green text we see the direction (For electrocardiogram, 64 lead or greater, with graphic presentation and analysis use 93799).

93799 is the unlisted cardiovascular service or procedure code. However, in the Category III section of the CPT® book we see codes for 64 lead EKGs (0178T, 1079T, 0180T) all with a sunset date of January 2018. If this is a service you provide, you should check with your payer for its preferred coding guidance.

Lastly we see "other qualified health care professional" language added in the preamble to the Hydration Injection and Infusion section (96360-96549) and inserted in to the moderate sedation codes.

A careful review of the new CPT® book is important to be aware of subtle changes that could have a big impact on your coding and reimbursement, says Granovsky.