Revenue Code 452 and Out-of-Network Providers
Question: Would you give us information on the correct use of revenue code 452? We are wondering if we can use it for our out-of-network Medicaid patients, because the claims are being denied as "out of plan." Would this revenue code be tied to the E/M level that was documented? Will they pay for this?
Montana Subscriber
Answer: Revenue code 452 (ER beyond EMTALA screening) may only be used in conjunction with revenue code 451 (EMTALA emergency medical screening services). You can't report it as a stand-alone code, and a HCPCS code must be reported with all type-of-bill (TOB) code 131 outpatient claims.
The problem you're encountering stems from plan restrictions, not necessarily the correct use of the revenue codes. Your best bet would be to contact the out-of-network provider and get the lowdown on eligibility, coverage, and billing guidelines.
Choose Debridement Over Amputation
Question: A patient presented in the emergency department with partial traumatic amputation of his distal fingertip, and it was determined that the fingertip could not be replanted. The physician used a bone rongeur instrument to debride and round the bone in order to close the wound over it. Should I report a debridement or an amputation code?
Virginia Subscriber
Answer: You should not report the code for amputation of the finger/phalanx, 26951 (Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure). Most of the amputation occurred before the patient arrived at the hospital, and the physician just cleaned up the amputation. Though the code bundles the closure, it doesn't accurately fit your scenario.
This scenario calls for a debridement and a simple closure code instead. Report the debridement as 11044 (Debridement; skin, subcutaneous tissue, muscle, and bone) because the physician definitely debrided not only the skin but also the muscle and bone. He then also closed the defect, so you should add a simple laceration repair code from the 1200x series to cover the extra resources of the closure. In this case, use 12002* (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6 cm to 7.5 cm).
Depending on documentation, you may also consider using the complex laceration repair code 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm).
Long Versus Short for Saphenous Vein Ligation
Question: What is the proper code assignment for saphenous vein ligation and partial excision, with trivex excision of multiple posterior calf tributary accessory veins?
Florida Subscriber
Answer: Since partial excision of the saphenous vein is included in the ligation code, you're going to need two codes here - one for the saphenous vein ligation and one for the excision of the cluster of veins.
The first part involves two distinctions: finding out whether the physician ligated the long saphenous vein, the short one, or both, and then determining whether the ligation was performed at a junction or the physician completely stripped the vein.
If either the long or short saphenous vein was stripped, use code 37720 (Ligation and division and complete stripping of long or short saphenous veins), but if they were both stripped, use 37730 (... of long and short saphenous veins). For ligation of the short vein at a junction, use 37780 (Ligation and division of short saphenous vein at sapheno-popliteal junction), and for ligation of the long one at a junction, use 37700 (... long saphenous vein at saphenofemoral junction, or distal interruptions).
In any case, the code for excision of the group of veins is 37785 (Ligation, division, and/or excision of recurrent or secondary varicose veins [clusters], one leg).
- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, president of SLG Consulting Inc. in Raleigh, N.C.
