Dermatology Coding Alert

Try your hand at 2 real-life scenarios

If your dermatology practice encounters denials for  injection administrations and E/M services, you need to know when - and when not - to appeal a denial for an injection and a separate E/M service on the same day.

Use these real-life dermatology billing scenarios to see if you know when you can bill E/M services and injections on the same day.

Think about whether you would dispute these denials and how you would solve these billing problems before reading the solutions below. 
 
Scenario #1: Our dermatology practice treats many patients with chronic psoriasis using Amevive injections once a week for 12 weeks. We've always billed for an E/M visit and the Amevive injections on the same day and have gotten paid with no problems. Suddenly some of our carriers started saying they wouldn't pay for both codes on the same day. 
 
Scenario #2: Our dermatologist has recently started administering Remicade injections, a proven treatment for rheumatoid arthritis and Crohn's disease, to our patients with severe psoriasis. We billed for E/M services long ago and the carriers denied our claims. Our dermatologist insists that we should bill for E/M services when we provide these injections, but I do not agree.

Billing Solution #1

Learn Your Private-Versus-Medicare Requirements

Many dermatologists have recently complained that payers simply decided to stop paying for medically necessary E/M services on the same day as intramus-  cular injections.

The answer to your denial problems may be in your level of documentation specificity and diagnosis coding.

Explanation: Private carriers will reimburse practices for injections and E/M services provided on the same day, but in some cases, private carriers require you to report difference injection codes than Medicare requires, says Linda Martien, CPC, CPC-H, of National Healthcare Review in Woodland Hills, Calif.

If your office is billing a private carrier, you may have to use CPT's injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

Remember that Medicare no longer accepts this code. Ask your private payer for its injection and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) policies.

Don't forget: Private carriers and Medicare also require you to justify the level of E/M you are billing, so your documentation should clearly justify your code choice, Martien says.

Solution: If you're billing a private carrier, contact them first to see which injection codes they require, Martien says. 
   
You can now bill Medicare for injections with the G series codes (such as G0351, Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) in addition to an E/M code (such as 99203, Office or other outpatient visit for the E/M of a new patient ...) and receive pay, Martien says.

Watch out: Be sure you attach modifier -25 to the E/M to show Medicare that it's a separate service, as long as you have the documentation to back it up, Martien says.

Tip: One way to ensure your documentation makes the grade is to double-check your documentation. Verify that the dermatologist clearly links one diagnosis code with the injection administration and an entirely separate diagnosis code to the E/M service, Martien says.

Example: An established patient who was previously treated for carcinoma visits your dermatologist one day complaining of scaly, red, irritated skin patches on her scalp and neck. After examination, your dermatologist diagnoses the patient with a serious case of psoriasis (696.1, Psoriasis; any type, except arthropathic).

The dermatologist then decides to administer an intra-muscular injection of Amevive (G0351) to treat the patient's psoriasis.

Because the dermatologist also performed a separately identifiable E/M to carefully examine several suspicious- looking moles on the patient's arms and back, you should bill for both an E/M (such as 99242, Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) and the injection, Martien says.

Careful: If your office schedules the patient to come in for an injection in advance and there's no reason to perform a separate exam, you most likely shouldn't bill for an E/M visit, Martien says.

Billing Solution #2

Level of Complexity Determines E/M Reporting

You can bill an E/M procedure with Remicade injections if you've met your carrier-specific guidelines and an appropriate level of E/M decision-making.

"Per coding guidelines, G0359-G0360 are the correct codes to use when performing Remicade infusions," says Linda Parks, MA, CPC, CMC, CCP, a coding specialist in Marietta, Ga.

Coding know-how: You should use G0359 for the initial hour of Remicade infusion. Assign G0360 (Each additional hour, one to eight [8] hours [list separately in addition to code for primary procedure]) in addition to G0359 when the physician or nurse provides an additional hour of Remicade infusion.

Code G0360 replaces +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]).

Try this: If your dermatologist or nurse administers three hours of Remicade to treat a patient, you should report G0359 for the first hour and G0360 x 2 for the additional two hours.

Important: Medicare intends for you to use the G codes just for this year, says Mary Brown, CPC, director of client services at Partners In Practice in Sarasota, Fla.

Next year, CPT will unveil new infusion and injection codes, which Medicare plans to accept. Remember that Medicare no longer accepts therapeutic/diagnostic infusion codes 90780-90781. "Commercial insurance carriers will decide on an individual basis whether or not to accept the G codes in 2005," Brown says.

As in the example above, as long as your documentation clearly justifies that the dermatologist provided E/M services that were completely separate from the Remicade injection, you should bill for your E/M services, coding experts say.