ED Coding and Reimbursement Alert

The use of a group of drugs known as thrombolytics (tPA, Streptokinase, Retivase, etc.) are some of an ED physicians most powerful weapons in treating patients who present in the middle of acute myocardial infarctions (MI) or shortly after suffering a stroke.
However, coders are often confused about the correct way to report the administration of thrombolytics in the emergency department. Different codes are used depending on the site of action for which the drug is intended, and Medicare does not recognize the physician work component involved, making reimbursement even more tricky.

Due to varying payer coverage policies, reimbursement for thrombolytic administration is almost always going to be complicated, advises John Turner, MD, medical director for documentation and compliance at TeamHealth, Inc., an emergency medicine staffing company based in Knoxville, TN, and a member of the American College of Emergency Physicians Coding and Nomenclature Advisory Committee.

However, there are some keys to correctly reporting the use of thrombolytics and to maximize the reimbursement for this service.

Clinical Background

Thrombolytics are clot-dissolving drugs administered intravenously to halt damage to the coronary arteries from an MI. A few years ago, doctors also discovered that intravenous infusion of one type of thrombolytic within a short time of the onset of symptoms helped to drastically reduce the long-term damage from cerebral infarcts (stroke).

While the drugs can be life-saving, in order to be useful they must often be administered as soon as possible after the onset of symptoms. They also carry the risk of significant side effects in some situations. In most cases, the drug is administered through a continuous infusion with the physician monitoring the patient for signs of adverse reaction until a specialist assumes care, says Turner.

Optimize Pay-up with Correct Codes

According to CPT, code 37195 (thrombolysis, cerebral; by intravenous infusion) should be used when thrombolytics are administered to treat stroke patients, and CPT 92977 (thrombolysis, coronary; by intravenous infusion) when the patient is treated for an MI, says Danelle Kelly, RN, CPC, CPC-H, a coding consultant with D. J. Kelly & Associates, Inc., an emergency medicine and hospital billing consulting firm in Schaumburg, IL.
Some readers have asked whether the code 37201 (transcatheter therapy, infusion for thrombolysis other than coronary) would be appropriate for use in reporting physician administration and monitoring of tPA infusions for MI patients.

Note: Code 37201 has a Medicare relative value unit (RVU) of 10.70 and a physician work component of 5.00.

But, emphasizes Kelly, this code [37201] indicates it should not be used for coronary treatment.

Again, she recommends the 37195 code rather than 37201 for cerebral infusions because 37195 specifically states cerebral, by intravenous infusion.

The concentration used for coronary arteries is totally different than that used for the cerebral infusion, advises Turner. When codes for thrombolytic infusion are utilized, it is important to choose the correct code to indicate the service performed (cerebral or coronary).

Medicare Doesnt Recognize the Physician Work Component

However, if the patient is a Medicare beneficiary, these codes should not be reported on the physicians Health Care Financing Administration (HCFA) -1500 claim form, Turner stresses. Although CPT indicates correct coding, Medicare considers the infusion therapy to be solely a facility service and reimburses the hospital for the nursing time, cost of the drug, and bed space with these codes, not for the physicians time and expertise. The total RVUs for these codes (92977 and 37195) are the same8.76, which indicates that Medicare does consider this an expensive service, he explains. But, if you look at the physician work component RVUs, they are zero.

Coders who routinely code the same for all payers can run into trouble with codes that private payers recognize and HCFA does not, he warns. Medicare has said numerous times that if you send in a claim knowing that it wont get paid, then that is a type of false claim, Turner says. You might send it in to the carrier on the HCFA-1500 and it gets paid [to the physician] by mistake. Coders who take the position that, Ive got a fee schedule and I treat all claims the same, and send it in to Medicare anyway are playing with hot coals.

The codes can be reported on the UB92 to indicate the level of resources used by the facility, says Kelly. But, in almost all cases, the patient will be admitted to the hospital and, for Medicare patients, this means the treatment received in the ED will be bundled into the hospitals DRG payment for the inpatient stay, she states.

I cannot think of a case where the patient would receive thrombolytics and then be discharged home, she says. The facility would not get separate payment from Medicare unless, perhaps, the patient died in the department.

Charging for the Physicians Service

In many instances of thrombolytic therapy, the patient is critically ill and often unstable, which means the physician would most likely be in constant attendance and reporting critical care services (99291-99292), Turner says. In addition, stroke patients require a significant workup to determine the patients eligibility to receive the drugs. The physician must order a CAT scan, and take a detailed medical history to rule out the potential for adverse side effects from receiving thrombolytics, Turner says.

For non-Medicare payers, the critical care services could be reported in addition to the codes for thrombolytic administration. A modfier -25 should be attached to the critical care code to indicate the performance of a separately identifiable procedure. But, for Medicare, the critical care evaluation and management (E/M) code is the only code that should be reported.

Fees for Non-Medicare Payers

Even though these codes can accurately be reported by physicians, according to CPT, the ED groups that base their fee schedule on Medicare RBRVS should re-examine their charge for thrombolytic infusion, Turner recommends. Medicare RVUs for this are 8.76, which is pretty high considering that a Level 5 emergency E/M service has 4.24 RVUs, he explains. The codes have a high number of RVUs, but, again, the RVUs listed under the physician component are zero. This indicates the high number of units for the code are intended to reimburse the facility for its expense, none of which involves the physician service. However, many ED groups base their fee schedules on the total RVUs attributed to a particular code. It is a way of being consistent across all procedures and codes, Turner says.

The groups will apply their own conversion factor, say $45, and multiply it by the number of RVUs for each code, to arrive at the fee for each service.

Something that has an RVU of 8.76 would come out to almost $400 using this conversion factor, whereas a level 5 E/M, by comparison, would only be charged at $200, he illustrates. That might be charging a lot more than what is reasonable for the physician portion of this service. Instead of choosing a new fee for this service, however, some groups have chosen to keep their RVU methodology and report a different code to private payers for thrombolytic infusion90780 (IV infusion for therapy/diagnosis, administered by physician), Turner says.

That code can be used for both the infusion for the coronary concentration and the cerebral concentration of thrombolytics. That isnt paid by Medicare either; it has no physician work component, but the facility RVUs are 1.21, he notes. In our example case above, that works out to about $55, which is low, but perhaps closer to the actual physician service.

Physicians can try to base their charge on the RVU amount for the thrombolytic infusion codes, but payers may refuse to pay that amount, and it is not truly reflective of the physicians work, Turner adds. Legitimately, there is no reason that any group cant code the 92977 or the 37195 for non-Medicare patients, as long as they are aware that they should look at their fee schedules and take an appropriate amount, rather than a knee-jerk conversion of the RVUs.

Turner also recommends checking with your private third-party payers to find out whether they will accept code 90780, or even 37195 and 92977. Sometimes payers will pay for one and not the other, he explains. You need to determine what code they will accept for this service. Some have coding edits that will throw out the 90780 and some will throw out 92977.