Internal Medicine Coding Alert

Published on Wed Jan 26, 2005 PDF

The latest edits could mean the difference between payment and denial

The National Correct Coding Initiative edits, version 11.0, bundles new injection and infusion codes G0345-G0354 into thousands of other codes - but don't let the numbers trip you up. You can bypass most of these edits as long as you use the appropriate modifier.

Why G0345 and G0104 Don't Mix

Medicare has made G0345 (Intravenous infusion, hydration; initial, up to one hour) and G0347 (... for therapeutic/diagnostic; initial, up to one hour) components of 5,687 codes. When appropriate, you'll be able to override all of those edits with a modifier, such as -59 (Distinct procedural service).

Of the edits, the ones that may impact an internal medicine office are those that make G0345-G0347 a component of colorectal-cancer screening codes G0104 (... flexible sigmoidoscopy), G0105 (...colonoscopy on individual at high risk) and G0121 (...colonoscopy on individual not meeting criteria for high risk).

Warning: Don't attach modifier -59 to either G0345 or G0347 just to "bypass an edit," says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise. "If you're going to use modifier -59, make sure that the physician performed a distinct procedural service," he says.

NCCI Targets Infusion/E/M Coding

NCCI also makes E/M codes 99201-99215 components of G0345-G0347. Even so, when appropriate, you can report G0345-G0347 with most new and established office codes if you attach 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.

For example, if the physician's documentation supported billing a level-two new-patient visit in addition to G0345, you'd report 99202-25 (Office or other outpatient visit for the E/M of a new patient ...; significant, separately identifiable E/M service ...).

Exception: You can't unbundle 99211 (Office or other outpatient visit ...) from G0345-G0347 because NCCI assigns it a "0" indicator, meaning no modifier applies to the edit.

Not being able to override edits governing 99211 makes sense, because CMS will only pay for "significant, separately identifiable" physician visits with infusion, says Cindy Parman, CPC, CPC-H, RCC, president-elect of the AAPC National Advisory Board and co-founder of Coding Strategies Inc. in Dallas, Ga.

2 Codes, Thousands of Edits

If you plan on reporting Medicare's new injection codes, G0351 (Therapeutic or diagnostic injection) and G0353 (Intravenous push, single or initial substance/drug), you should know they are now components of a combined 1,200 codes, including many from surgery and medicine. Fortunately, a modifier will override these edits.

Example: Suppose the internist wants to bill for both a trigger point and therapeutic injection. You would report 20552 (Injections[s]; single or multiple trigger point[s], one or two muscle[s]) and G0351-59 (Therapeutic or diagnostic injection; distinct procedural service).