ED Coding and Reimbursement Alert

Thrombolytics, with open blocked vasculature, have been used in the emergency department for years to treat patients with specific heart conditions. More recently, these medications are being administered to stroke patients to relieve immediate symptoms, minimize damage and reduce long-term effects. With either the more conventional or the emerging application of this therapy, reimbursement is not assured. Coders play a significant role in the payment process by learning the appropriate codes to assign and by understanding which alternative codes might be accepted if the initial claim is rejected by payers.

Individuals presenting to the ED with symptoms of acute myocardial infarction (MI) (e.g., 410.01, Acute myocardial infarction, of anterolateral wall; initial episode of care) might be treated with coronary thrombolysis. ED physicians regard this therapy as the clinical standard of care and order the administration of a thrombolytic agent to open any vascular occlusions interfering with the cardiac function. While CPT provides only two codes (92975, 92977) that describe this type of therapy, they are often misused or interchanged, says John Turner, MD, FACEP, medical director for coding and documentation at TeamHealth Inc. in Knoxville, Tenn.

The first of these codes listed in CPT is 92975 (Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography). "Because the first words in the definition are thrombolysis and coronary, coders are quick to assign 92975. It is confusing," Turner says. "However, this is incorrect because the remainder of the definition makes it clear that 92975 is a surgical procedure. Intracoronary infusion is administered directly through the coronary artery, which requires the physician to thread a catheter from the femoral artery through the vascular system up to the coronary artery. This procedure is not conducted in the ED."

Instead, he says, coders must look beyond the first code and assign 92977 ( by intravenous infusion). "This is the code used to report thrombolysis when the physician orders a large IV and has the medication delivered as a bolus."

Turner notes that when cerebral thrombolytic agents are administered to stroke patients (e.g., 436, Acute, but ill-defined, cerebrovascular disease), coders assign 37195 (Thrombolysis, cerebral, by intravenous infusion). This service is provided less frequently than coronary thrombolysis because its value is still being debated. "Neurologists dont agree on the effectiveness of cerebral thrombosis," Turner says.

Before cerebral thrombolysis is even considered as a treatment option, he says, a number of diagnostic studies must be done quickly, including a physical exam, blood work, and a CT scan (e.g., 70460, Computerized axial tomography, head or brain; with contrast material[s]) to rule out intracranial bleeds. Among the conditions that cause a stroke are hemorrhages, blood clots or obstructions caused by plaque buildup. Thrombolytics act as thinning agents, which effectively break up occlusions, but would only exacerbate hemorrhages.

"The ED physician considers the age and history of the patient, as well as the degree of involvement and the amount of deficiency resulting from the stroke, when determining whether or not to use thrombolysis," Turner says.

Besides assigning the correct infusion code, Turner says ED coders should report other typically provided services in addition to coronary and cerebral thrombolysis, such as any E/M services or diagnostic studies. For instance, the patient may be intubated (31500, Intubation, endotracheal, emergency procedure), and an EKG (e.g., 93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) may be performed.

"Determining the E/M code is sometimes tricky," Turner says. "Based on the physicians documentation, the coder may have to decide whether an upper-level E/M visit is appropriate (e.g., 99285, Emergency department visit) or if the service is more appropriately described as critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, and add-on code +99292, each additional 30 minutes [list separately in addition to code for primary service])." Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be appended to the E/M code assigned.

CPT defines a level-five emergency visit (99285) as requiring a comprehensive history and a comprehensive examination, with medical decision-making of high complexity. An illness or injury is defined as critical if it acutely impairs one or more vital organ systems that jeopardize the patients survival, says Mary Beth Loebl, CPC, senior consultant with Healthcare Consultants of America Inc., based in Augusta, Ga., and a coding instructor accredited by the American Academy of Professional Coders (AAPC). "The code definition describes a very high level of medical decision-making to assess, manipulate and support a variety of complex conditions."

Ideally, the ED physician will make a note in the medical record that services provided were critical. If not, Turner recommends that coders learn as much as possible about the clinical condition being treated and communicate directly with the physician about the appropriate level of E/M code to assign. The intent of this communication is clarification and education only, and could not be used to affect coding of the current patient record.

Loebl notes that some ED coders believe that patients must be "coding" for care to be characterized as critical. However, with changes in CPT definitions in 2000, that is no longer the case. The definition now reads: "A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration of the patients condition." Once the physician has provided a certain level of medical treatment, the patient may no longer be in danger of crashing. In that sense, the patient has been stabilized. But, if the medical intervention is removed, the patient probably could not maintain stability; he remains critically ill. Loebl also emphasizes that critical-care services need not be provided in a designated critical-care unit (e.g., intensive-care unit). "The emphasis is on the level of care the patient requires, not where it is delivered," she explains.

Additional criteria must be met for critical-care services to be billed for a patient receiving coronary or cerebral thrombolysis. The physician must be physically present in the ED and providing full attention to the patient in order to record critical care, although the time spent on a patients care need not be continuous. Turner reminds coders that some procedures are bundled into critical care and cannot be billed separately (e.g., 94656,Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day). Likewise, while unbundled services may be reported separately (e.g., 12034, Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm), the time spent providing the services cannot be counted toward the critical-care time. He advises ED physicians to note the time it takes to perform nonbundled services on the chart with the statement, "Time for separately billable procedures not included in critical care."

Even when properly documented and reported, this therapy raises questions. Many payers, including Medicare, may not reimburse for either coronary or cerebral thrombolysis, Turner says.

"One of the questions most frequently asked is if coders can report 92977 and 37195 when the physician did not personally administer the medication through the IV," he says. "Usually this is done by the nurse. This is where the doctor can bill a service that another healthcare professional performs. Because of the severity of the patients condition, the physicians presence and direct supervision become necessary. When coronary thrombolysis is administered, for instance, the patient often experiences unusual rhythms and possibly a pause in the heart rate. The physician observes closely to ensure the therapy is having the desired effect."

In many instances, Turner warns, 92977 and 37195 may be denied by private payers and Medicare carriers. "It is a high-ticket treatment, and some insurers avoid paying for expensive treatments." If this occurs, one possibility is to resubmit the claim, reporting the thrombolysis with 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). "While 90780 is usually reported when the physician administers medication to a hypertension patient whose blood pressure needs to be lowered immediately or to a heart patient requiring a nitroglycerin drip, the code does not disallow thrombolytics. It is perfectly acceptable to report 90780 for this use." As always, coders should ask individual payers if alternative coding is permissible.

Turner adds that 90780 is a lower-paying code and that there are no guarantees that insurers will reimburse for it. However, it provides an alternative for physicians to receive partial reimbursement for their services.