ED Coding and Reimbursement Alert

And check out new guidance on wound, burn and ultrasound services that could affect your revenue.

ED coders can look to the E/M section of their 2012 CPT® manual for most of the relevant changes and additions. But beware: Most of these are subtle references to time in applicable E/M code ranges, often hidden in preambles and parenthetical references that are easy to miss.

Read on for guidance on identifying the ED specific changes that could affect your claims, come Jan. 1, from Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a coding and billing company in Bedford, MA.

Heed Revised Definitions of New and Established Patients

2012 brings new wording to the New and Established Patient section in the E/M services guidelines in the front of the CPT® book. The underlined passages in the text below show the revisions:

"The definition of a new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. Similarly, an established patient is one who has received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years."

Although this new language does not impact the 9928xemergency department E/M codes directly, more and more groups are being tasked with expanding their services beyond the Emergency Department, says Granovsky. "As ED groups grow in their search for alternative revenue streams and the healthcare delivery system evolves towards greater integration, many groups are staffing separate urgent care clinics where the distinction between new and established patient status will play a critical role in determining code selection and subsequent reimbursement," he adds.

Note New ED Time Tip Included for 2012

Look for new "Coding Tips" advice in the CPT® E/M section on the significance of time as a factor in making your E/M code selections. "This is not new information but serves as a reminder that the inclusion of time is there to assist physicians in selecting the appropriate codes and that the listed times are averages and therefore represent a range of times that may be higher or lower, depending on clinical circumstances," says Granovsky.

Key: The ED coding tip reiterates that time is not a factor in selecting ED E/M codes.

Focus on Time Changes in Observation Codes

The initial observation codes (99218-99220) have new language listing typical times spent at the bedside and on the patient's floor or unit added, says Granovsky. See the complete new descriptors below with underlined new passages for 2012:

99218 -- Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission to "observation status" are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

99219 -- Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission to "observation status" are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

99220 -- Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission to "observation status" are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.

Nuance: Granovsky notes that typical times do not appear in CPT® 2012 for the Observation codes (99234-99236) used to describe observation care services for patients admitted and discharged on the same calendar date.

Use Prolonged Services Codes With Initial Observation

These typical time additions to the initial observation codes come into play with new language relating to the prolonged services codes. The preamble to the prolonged services section contains new language defining direct patient contact as face-to-face, including additional non-face-to-face services on the patient's floor or unit of the hospital during the same session. Accordingly, the term "face-to face" no longer appears in the title of the prolonged services code preambles. The phrase or "other qualified provider" following the term "physician" where applicable is also new in this area for 2012.

More importantly, says Granovsky, code +99356 (Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient Evaluation and Management service]) has a parenthetical list of applicable code ranges that now include the initial admit to observation codes.

One of the basic requirements for a reporting time-based add-on code is that "a typical or specified time (is) published in the CPT® book." Now that the 99218-99220 codes have published typical times they qualify for potential application of the +99356 add on code, says Granovsky. The specified code list allowing the application of +99356 appears in CPT® 2012 as below:

(Use 99356 in conjunction with 99218-99220, 99221-2-99223, 99251-99255, 99304-99310, 90822, 90829).

Don't Overlook These Wound, Burn, Ultrasound Changes 2012 introduces a small tweak in the laceration repair code preamble replacing the instruction to report wound repairs of different classification, as well as those involving nerves blood vessels and tendons, in a complex repair using modifier 59 (Distinct procedural service) rather than the 51(Multiple procedures) as in years past.

A subtle change also appears in the applicable code range preamble for the burns section; local treatment codes (16000-16036) is altered from 15100-15431 to 15100-15278 to account for new skin graft codes and to remove the codes deleted in the 2012 book.

New code alert: Three new codes appear in the Abdomen, Peritoneum, and Omentum section of the digestive system surgery area, primarily as replacements to the deletion of previous codes 49080 and 49081 due to changes over time in the specialty that most frequently provides the service. These are codes 49082 and 49083 (Abdominal paracentesis [diagnostic or therapeutic] without and with imaging guidance) and 49084 (Peritoneal lavage, including image guidance when performed). New parenthetical references following these codes that indicate ultrasound, such a as 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation), is no longer separately reportable service, Granovsky points out.

Look for updated preamble language for diagnostic ultrasound, particularly for ultrasounds of vascular structures using color and spectral Doppler. However the only 2012 change is to update the code range to reflect the deletion of code 93875 (Non-invasive physiologic studies of extracranial arteries, complete bilateral study [e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis]).

Immunization administration for vaccines/toxoids gets a slight tweak in the code ranges to add codes 90471-90474 and a new statement to the paragraph about component and combination vaccines, as follows: "Conjugates and adjuvants contained in vaccines are not considered to be component parts of the vaccine as defined above." Of note, code 90470 for reporting the administration of the H1N1 vaccine product from the 2009 pandemic has been deleted in 2012, since that vaccine is no longer offered, adds Granovsky.

Resource tip: A complete list of all the changes for 2012 can be found in Appendix B summary of Additions, Deletions and Revisions found on page 572 of the 2012 CPT® book. Granovsky recommends Review this appendix upon receipt of the new CPT® book to identify changes to codes of interest to your particular practice, Granovsky recommends.

Editor's note: Look to future issues of ED Coding Alert for more on CPT® 2012 changes.