ED Coding and Reimbursement Alert

The 2016 CPT® book added 140 new codes, revised an additional 134 more and deleted 92 prior codes for a total of 366 changes. Our experts give you the news you need for ED coding to get you ready for January.

New Prolonged Codes Revised to Include Psychotherapy Services

There is only one minor change to the ED E/M codes, but ED groups should be aware of four changes to the prolonged services codes, says Michael Granovsky, MD, FACEP, CPC, CEDC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA.

The ED E/M change is in the description of 99284, a level 4 ED visit. Although easy to miss because of how it appeared on the page, for the past few years there has been an extra word "physicians" included in the sentence about the nature of the presenting problem.

• "Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician physicians, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function."

That typo has been removed in the 2016 book, but how many coders have ever noticed it was there? Importantly, the change does not impact the definition or application of the code, states Granovsky.

Bigger deal: Look for two new and two revised prolonged services codes. The current prolonged service codes for outpatient services (99354-99355) were revised to apply to either E/M or psychotherapy services performed by a physician or other qualified health professional.

• 99354 (Prolonged evaluation and management or psychotherapy service(s) [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service])
• 99355 (...each additional 30 minutes [List separately in addition to code for prolonged service])

The two new codes (99415-99416) cover prolonged services by a member of the clinical staff in the office or outpatient setting. The new codes may be used in conjunction only with 99201-99215 so are not available for use in the ED because there is not time associated with ED E/M codes.

However, the existing prolonged codes will still be used in conjunction with psychotherapy and E/M codes, including all three categories of observation services using prolonged services codes 99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient Evaluation and Management service]) and 99357 (...each additional 30 minutes [List separately in addition to code for prolonged service]).

Despite the changes, the ED 9928x codes (which do not have typical times published by CPT®) would not qualify for application of the prolonged service codes.

Input This New Cerumen Impaction Removal Code

New for 2016 is a separate code for removing impacted cerumen that does not require use of tools like the current code 69210 (Removal impacted cerumen requiring instrumentation, unilateral). The new code covers the procedure if only irrigation or lavage is used to remove the wax. If this is the procedure actually performed in the ED report code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral).

Red flag: Code 69209 should not be reported in addition to the current code 69210. If you start the procedure using irrigation but subsequently determine that an instrument is need to clean out all the cerumen, report only 69210, says Granovsky.

Example 1: A patient without a primary care provider comes to the ED with flu like symptoms and complaining of clogged ears. In the course of the physical exam, it is noted that there is mild cerumen impaction that must be cleared for a better ear exam. The impaction is removed with irrigation to the point that the ear drum can be better visualized. Assign code 69206

Example 2: A 49-year-old male presents to the ED complaining of ear discomfort along with a recent worsening of hearing in the left ear over a several-day period. Physical exam shows a cerumen impaction filling the entire external auditory canal. The emergency physician physically removes the cerumen from the canal with instrumentation and magnification. Assign code 69210

Remember: For cerumen removal that is not impacted, CPT instructs only reporting the appropriate E/M service code and specifically includes 99281-99285. If you perform the procedure bilaterally, append modifier 50 to the appropriate cerumen removal code, he adds.

Radiology Codes For Spine And Lower Extremities Have Been Revised:

For those ED groups and urgent care centers billing for x-ray services, take note of the 2016 changes and be sure to update your charge master.

Radiology section changes for 2016 include the radiological exam codes for spine, hip and pelvis with several codes being deleted (72010, 72069, 72090, 73500, 73510, 73520, 73530-73550) and replaced with new codes (72080-72084, 73501-73503, 73521-73523 and 73551-73552).

Several of the spine codes are typically used to evaluate scoliosis, which would not be common in the ED; however, traumatic injury could resort in most of these being ordered in an ED setting.

For Example:

72082 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views

Report 72082 to report plain x-ray images of the entire thoracic and lumbar spine taken from two or three angles or directions (projections); the images may include the skull, neck (cervical spine) and tailbone (sacral spine), so, if included, do report a separate code.

In other cases, the new codes describe bundling of previously separate codes. For example, when it was noted that most hip x-rays also had an image of the pelvis 72170 (Radiologic examination, pelvis; 1 or 2 views), CPT® decided that the pelvis should be bundled in with the hip x-ray. Previous code 73500 (Radiologic examination, hip, unilateral; 1 view) was deleted and replaced in 2016 with code

73501 (Radiologic examination, hip, unilateral, with pelvis when performed; 1 view). 

Use 73501 to report a single plain X-ray of one hip, either the left or the right but not both. If the image includes the entire pelvis, that is included so not report separately.

For a complete list of the new codes in the radiology Section, visit the Codify website at: https://www.aapc.com/codes/.

Check Out New/Revised Vaccine Codes

With each new CPT® book, we traditionally see changes to the vaccine codes to reflect the most recent strains or changes in the code descriptors and deletion of obsolete codes. In 2016, this section has 15 new, 50 revised and 19 deleted codes.

Remember that in CPT®, new codes are marked with a red dot • and revised codes with a blue triangle ▲. As codes are revised or resequenced, several will now appear out of numerical order, which CPT® indicates using the # symbol and a notation in red text where the code would logically appear (90644 Code is out of numerical sequence. See 90476-90749). A lightning bolt symbol ~, means the code is pending FDA approval.

Common Vaccines Have New Code Assignments In 2016

Although there are 50 new codes in the entire medicine section, these four vaccine codes might be used in the ED Setting.

 • 90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use

#~• 90625 Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use (90727 has been deleted)

# • 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intramuscular use

# • 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for intramuscular use (90735 has been deleted)

Revised Codes Reflect Minimal Changes

Most of the revised codes have minimal changes such as adding an abbreviation such as (HepA) for hepatitis A, (Hib) for Haemophilus influenzae type b, (IIV) for inactivated, (II3V) for trivalent or (IIV4) for quadrivalent in  in the code descriptor

▲ 90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular use

▲90647 Haemophilus influenzae type b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for intramuscular use

~▲ 90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use

▲ 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

# 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use.