ED Coding and Reimbursement Alert

New introduction to US section in CPT 2005 creates hurdles

Usher in the new year - sans grace period - with loads of new procedure codes that will change the way your ED functions. Come Jan. 1, you'll need to familiarize yourself with the new ultrasound requirements, changes to conscious sedation coding, and revamps to critical care codes for 2005 - and that's just the beginning of the updates.

Home In on 2 Key Areas for US Changes

The updates to ultrasound (US) reporting that you'll need to know fall into two major groups: the requirements in the section introduction, and changes to the definitions of abdominal and retroperitoneal US codes.

The new guidelines. CPT has rewritten the introduction to the US section to include changes that hike the standards for emergency department US billing.

For example, for anatomic regions that have both "complete" and "limited" codes - such as the abdomen (76700, Ultrasound, abdominal, B-scan and/or real time with image documentation; complete and 76705, ...limited [e.g., single organ, quadrant, follow-up]) - there are now specific instructions that say you must meet all the requirements for the complete study to report the "complete" code. If you don't meet all the requirements for a "complete" exam, you have to report the "limited" code, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI in Stoneham, Mass.

These instructions also warn you not to report both a "limited" US exam and a "complete" exam of the same anatomic region in the same session, Granovsky says.

Requirement: If the ED physician uses ultrasound guidance without thoroughly documenting an evaluation of the affected organ or anatomic region, documenting the image, and creating a final written report, you can't separately report the US guidance code. CPT repeats this guideline at least three times in this section, just so you know they're not kidding.

Definition of "complete" US is now more complete. For the code set 76700-76778, which describes abdominal and retroperitoneal US guidance, "complete" now includes specific areas that the physician must evaluate in order to bill a separate US service, Granovsky says. For the abdomen, for example, a "complete" US includes the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, aorta, and inferior vena cava.

Wake Up for Appendix G

While the definitions of 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (... oral, rectal, and/or intranasal) stay the same, prepare for bunches of bundles. As of Jan. 1, 2005, the work involved in administration of conscious sedation will be included in a host of previously untouched codes.

Many practices won't find the bundles to be a surprise. "Many insurance companies - including Medicare - wouldn't reimburse conscious sedation services, no matter how many hoops you'd jump through," says Michelle Bailot, CPC, medical coding specialist at SVA Healthcare Services.

According to Appendix G, in which these codes are listed, the following list of procedure codes for CPT 2005 includes conscious sedation as an inherent part of providing the procedure. Here are some of the most ED-relevant codes that now include conscious sedation:
  32020 - Tube thoracostomy with or without water seal (e.g., for abscess, hemothorax, empyema)
 (separate procedure)
  33010 - Pericardiocentesis; initial
  33210 - Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
  36555 - Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
  36570 - Insertion of peripherally inserted central venous access device, with subcutaneous port; under 5  years of age
  36571 - ... age 5 years or older
  43200-43272 - Endoscopy
  92953 - Temporary transcutaneous pacing
  92960 - Cardioversion, elective, electrical conversion of arrhythmia; external.