ED Coding and Reimbursement Alert

Emergency department coders must pay close attention to language changes in the front matter of CPT 2002, according to Michael Beebe of the AMA. He notes that the modification represents a "subtle, but major change" in how ED physicians and coders report services that are not precisely described by an existing code. Beebe provided this information during the AMA's CPT 2002 Coding Symposium in Chicago, Nov. 15 and 16, 2001.
 
Instructions about coding these services may be found in the Introduction section of the CPT 2002 manual (page x), under the heading "Instructions for Use of CPT." The new directions read (revisions appear in italics):
 
Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. In surgery, it may be an operation; in medicine, a diagnostic or therapeutic procedure; in radiology, a radiograph. Other additional procedures performed or pertinent special services are also listed. When necessary, any modifying or exten-uating circumstances are added. Any service or procedure should be adequately documented in the medical record.
 
It is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.

Emphasis on Unlisted-Procedure, Category III Codes

According to David A. McKenzie, director of reimbursement for the American College of Emergency Physicians in Irving, Texas, in the past, directions simply noted that coders should "select the name of the procedure or service that most accurately identifies the service performed," without giving further instructions to use unlisted-procedure codes.
 
Beebe notes that the AMA's primary objective in implementing the modification is to help prevent miscoding of new services. To accommodate this shift in policy, additional unlisted-procedure codes have been added to various sections and subsections of CPT, and more are anticipated in future years. In addition, CPT 2002 contains 22 Category III codes, developed to track the use of new and emerging technologies and services. (Codes now in place are considered Category I codes.) Placed in the CPT manual between the Medicine section and Appendix A, the temporary Category III codes are alphanumeric (e.g., 0021T, insertion of transcervical or transvaginal fetal oximetry sensor) and their use is optional, Beebe says. However, CPT 2002 instructions indicate that, if available, a Category III should be reported instead of an unlisted-procedure Category I code. No relative value units (RVUs) have been attached to Category III codes.
 
Besides affecting new procedures, this new introductory language may impact coding established services. For instance, physician documentation for laceration repair (12001*-13160) may not include the specific length of the wounds repaired, which is vital to choosing the correct code. When this information is missing, coders must default to the lowest-level code in the series. For example, the patient record may refer to a layered closure of the scalp, but omit the length of the wound. The coder may simply assign 12031* (layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) instead of a higher-paying code like 12035 ( 12.6 cm to 20.0 cm). Although it is unlikely that a practice would be accused of fraud for billing a minimum-service code in circumstances like this, the new CPT instructions raise this possibility.
 
The new language also makes it clear that services listed as, or assumed to be, physician services may also be reported when provided by other qualified healthcare professionals, e.g., advance practice nurses, physician assistants, etc.

Other Significant CPT Changes

CPT 2002 contains additional changes of interest to emergency physicians:

Surgical Package. The AMA has enhanced the definition of a surgical package for 2002, including new language that clarifies what is included. Found on page 43 of the CPT 2002 manual, Professional Edition, under the heading "Surgical Guidelines," the modified explanation specifically outlines which services are always included in a procedure package:
 

local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;

subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical); 
 

immediate postoperative care, including dictating operative notes, talking with the family and other physicians;
 

writing orders;
 

evaluating the patient in the postanesthesia recovery area;
 

typical postoperative follow-up care.
 
Patient Transport. At times, particularly in rural areas, emergency physicians may provide patient transport services, defined by two new codes in CPT 2002:

99289 physician constant attention of the critically ill or injured patient during an interfacility transport; first 30-74 minutes

99290 each additional 30 minutes (list separately in addition to code for primary service).

These codes are used only for direct, face-to-face care by a physician while a critically ill or injured patient is being transported from one facility to another via ambulance, helicopter or fixed-wing airplane, according to CPT. The first 30 minutes of care is not reportable with these codes. Services provided and procedures performed during transport may be reported in addition to 99289 and 99290, with the exception of routine monitoring (e.g., heart rate, respiratory rate, blood pressure, pulse oximetry) and initiation of mechanical ventilation. Critical care codes (99291-+99292) should not also be reported when 99289 and 99290 are used.

Casting. In the upcoming year, emergency physicians may use a new code to describe casting of a single finger:  29086 (application, cast; finger [e.g., contracture]).

Anesthesia. CPT has also implemented a requirement that a "physical status modifier" be used when emergency and other specialty physicians report anesthesia procedure codes. The physical status modifiers, which reflect the American Society of Anesthesiologists' ranking of physical status, are:

 P1 A normal healthy patient
 P2 A patient with mild systemic disease
 P3 A patient with severe systemic disease
 P4 A patient with severe systemic disease that is a constant threat to life
 P5 A moribund patient who is not expected to survive without the operation
 P6 A declared brain-dead patient whose organs are being removed for donor purposes.

These modifiers will be appended directly to all anesthesia codes (e.g, 01810, anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand) and reflect the level of complexity associated with the anesthesia service provided. They do not apply to conscious sedation.