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 [...]