Pulmonology Coding Alert

Question: My doctor started an infusion procedure on an established patient in an outpatient setting. He spent four hours at the hospital monitoring the procedure. I reported 99219 for the E/M service, 90780 for the first hour of the infusion, and 90781 for each of the second, third and fourth hours. The carrier only paid on 99219. Would you tell me if I charged this incorrectly?


Maryland Subscriber

Answer: Check to see if the infusion codes you're reporting are valid. Medicare, for example, only recognizes the temporary HCPCS codes G0347 (Intravenous infusion, for therapeutic/diagnostic [specify substance or drug]; initial, up to one hour) and G0348 (Each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure and report in conjunction with G0347]) for infusion.
 
Therefore, your carrier for this claim may not recognize CPT's 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) or +90781 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]), which the AMA will most likely delete in 2006.

Tip: You should also remember that infusion codes require physician supervision during the procedure. The payer probably wants to be sure that the observation visit you reported using 99219 (Initial observation care, per day, for the evaluation and management of a patient ...) is in fact separate from the observation required for the infusion procedure.
 
If this is the case, you 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 99219 to make it clear to the carrier that the E/M service is separate from the procedure. Also, make sure the ICD-9 codes you report for the E/M service are different from the ones you use for the infusion.

Location could be another problem. Even though your physician performed the service as an outpatient procedure, it took place in a facility setting (e.g., the emergency department or observation area of a hospital). The facility, not the physician, usually reports infusions in these types of settings, since the hospital staff performs the infusion and the drugs used represent a cost to the facility, not to the physician.
  
Learn the carrier's infusion guidelines. Some payers only consider infusion of certain substances or for certain indications to be medically necessary. You should also check the carrier's guidelines on paying for more than one service per day. Some insurers only allow one service per day (either the procedure or the visit), regardless of medical necessity.

Answers for You Be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Alan L. Plummer, MD, professor of medicine, division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta.