ED Coding and Reimbursement Alert

Not all CPT definitions apply equally to the ED setting. What may be appropriate for private-practice physicians doesnt always work in an emergency. One prime example of this is coding for infusions in the ED.
 
ED coders struggle over what code to use for IV infusion therapy because Medicare considers what appears to be the obvious choice, 90780, a Part A service only. This policy throws coders off because it seems to counter the emphasis CPT places on the role of the physician in its definition of 90780 (IV infusion for therapy/diagnosis, administered by or under direct supervision of physician, up to one hour).
 
ED physicians and coders question why CPT would word 90780 in this manner if its not reimbursed by Medicare. Confusion often arises because Medicare carriers adhere to CMS coding and reimbursement rules while most non-Medicare payers follow CPT rules. Many times CMS and CPT conflict with what they consider reimbursable, and this is one such occasion.
 
For those insurers that do not follow CMS coding guidelines, 90780 will be paid and can be used per the CPT guidelines, says John Turner MD, PhD, medical director of documentation and coding compliance for Team Health in Knoxville, Tenn. 
 
Ironically, even though Medicare wont pay and there is no physician-work component built in to the code, ED coders need verification of the physicians participation. Its very risky to bill the services directly from the orders if theres a possibility the nurse or someone else performed the IV, says Tracie Christian, CPC, CCS-P, coding specialist for Pro-Code Inc. in Dallas.
 
Documenting Infusion Time

 
Code 90780 is time-based, so it is critical for nursing staff and physicians to clearly account for their time during the infusion. Physicians neglect to document the time for ED services because they are typically provided on a variable-intensity basis, often involving multiple encounters with several patients over a long time.
 
I believe that to document the physician-work component the ED physician should record several bedside assessments during the hour, says Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, an emergency physician group based outside of Washington, D.C.
 
It is difficult to remember that 90780 must be timed, particularly when most time-based codes are not typically seen or used in the ED. The ED physician performs many different services and the patient could  be there for 20 hours, so the time factor is difficult to gauge.
 
However, we do see many patients in the ED with presentations that warrant IV infusion therapy with physician administration and supervision, Christian says. For example, a patient presents with trouble breathing (786.9) and throat swelling (784.2) due to an allergic reaction, and the ED physician orders IV Solu-Medrol (90780) to be administered over 60 minutes.
 
Often, the ED physician needs to recheck the infusion and indicate on the chart the time spent doing this and any other changes in the patients status. If the ED physicians supervision encompasses a combined time of one hour (the time does not have to be continuous), 90780 would be appropriate if the documentation verifies the physicians direct supervision and the times involved. If the infusion extends beyond one hour and this time is documented, also use 90781 ( each additional hour, up to eight [8] hours, [list separately in addition to code for primary procedure]).
 
For example, a patient presents with severe pedal edema (782.3) resulting from chronic heart failure (i.e., 428.0). The ED physician orders IV Lasix to be administered over the next 90 minutes. In this example, ED coders would report the infusion with 90780 and 90781.

 
Due to potential side effects (i.e., hypotension) or titration of the desired effect (i.e., seizing stops or blood pressure normalizes) caused from some of the drugs administered by infusion therapy, the physicians participation is necessary. 
 
In the past, we tried to apply IV infusion codes for basic fluids (i.e., saline) but have been told that it is not appropriate, so we stopped, says Martin Herman, MD, president of Pediatric Emergency Specialists and assistant director of emergency services for LeBonheur Childrens Medical Center in Memphis, Tenn.
 
Granovsky says that if EDs assume that physician work is associated with infusion therapy, the following drugs seem like reasonable examples of when 90780 should be coded:
 
Cardizem   Dilantin   
Dopamine  Epinephrine
Insulin drip  Nitroglycerin   
Tertbutaline

 
Granovsky said there are more drugs to mention, but patients routinely receive them in critical-care cases. Dilantin, Diltiazem and Nitroglycerin make up the majority of infusions for noncritical-care patients.

 
Infusion therapy is frequently used in critical-care situations. But not all critically ill patients are billed as critical care (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; and 99292, each additional 30 minutes) because the time at the bedside is less than the requisite 30 minutes, Herman says.
 
It is important that time spent performing separately billable procedures like infusion therapy in the ED not be calculated into critical-care services. Just because a drip is hung over an hour does not mean the physicians work took that entire hour. You can estimate the time required for the ED physicians effort and deduct that time from the critical care given in the ED.
 
In the real world, the infusion codes are most frequently billed when the care does not qualify for 99291 [due to time or severity of illness], Granovsky says.

 
Although Medicare does not apply a physician-work component for 90780, other payers will recognize the physician component, particularly when the doctor documents his or her participation and time for the infusion administration, Christian says. The bottom line is that for the payers who follow CPT rules, when the CPT description of the code is met with the proper documentation, we code it, she says. Physicians should focus on providing patient care and treatment and not on payer policy, she concludes.