ED Coding and Reimbursement Alert

It's official: CPT 2008 includes changes to the hydration, injection and infusion codes that will prevent their further use by physicians in the ED. However, next year's CPT book is also offering some new codes for tube procedures and behavior change counseling that ED coders can take advantage of.

Check out this rundown of the CPT 2008 changes ED coders need to know about.

"We are seeing significant changes in the hydration, injection and infusion codes appearing in CPT 2008, disallowing use by physicians in the ED setting," confirms Michael Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.

Explanation: For 2008, CPT states, "Physician work related to hydration, injection and infusion services predominately involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting."

Impact: Granovsky reports that in 2008, you won't be able to report the following codes in the ED setting:

- 90760 -- Intravenous infusion, hydration; initial, 31 minutes to 1 hour

- +90761 -- - each additional hour (List separately in addition to primary procedure)

- 90765 -- Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour

- +90766 -- - each additional hour (List separately in addition to code for primary procedure)

- +90767 -- - additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)

- +90768 -- - concurrent infusion (List separately in addition to code for primary procedure)

- 90769 -- Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s)

- +90770 -- - each additional hour (List separately in addition to code for primary procedure)

- +90771 -- - additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)

- 90772 -- Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

- 90773 -- - intra-arterial

- 90774 -- - intravenous push, single or initial substance/drug

- +90775 -- - each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

- +90776 -- - each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)

(Note: Codes 90769 through +90771 and +90776 are new for 2008).

When you perform these procedures in the ED, Medicare considers the physician's supervision part of the E/M service. "Absent advice from other payers, you should consider this universal policy at this point based on the 2008 CPT changes," Granovsky advises.

Remember: The hydration, injection and infusion codes may still be reported by the facility in 2008; but these codes are off-limits for ED physician use.

You-ll use three other new codes when your physician utilizes fluoroscopy and replaces a gastrostomy or cecostomy (or other colonic) tube, a duodenostomy or jejunostomy tube, or a gastro-jejunostomy tube.

In 2008, choose from one of the following codes for these types of tube replacements:

- Report 49450-(Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) when the ED physician replaces a gastrostomy or cecostomy tube.

- Report 49451-(Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) when the physician replaces a duodenostomy or jejunostomy tube.

- Report 49452-(Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) when the physician replaces a gastro-jejunostomy tube.

For straightforward gastrostomy tube (G-tube) changes without fluoroscopy, use 43760. CPT 2008 also changes the wording of 43760 for 2008: The new descriptor reads "Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance."

The new wording clarifies that the change of gastrostomy tube is percutaneous and "without imaging or endoscopic guidance." These procedures are more common in the ED than tube insertions with fluoroscopy, so you-ll use 43760 more often than the other tube insertion codes.

Example: An elderly female is brought in by ambulance from the nursing home because her G-tube is dislodged. The physician orders a replacement G-tube to the bedside and places it through the well-established percutaneous tract. After placement the physician aspirates gastric contents, confirming that the tube is safely within the stomach.

For this encounter, report 43760.

Code for Counseling Sessions of 15+ Minutes

If patients present to the ED and the physician performs a structured alcohol/substance abuse screening, you-ll be able to report one of the following CPT codes:

- 99408--- Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

- 99409 -- - greater than 30 minutes.

According to CPT, you should observe these restrictions for 99408-99409:-

- Report 99408 only if the counseling service lasts at least 15 minutes

- Do not report 99409 with 99408

- Do not report 99408, 99409 with 99420

- Use 99408, 99409 only for initial screening and brief intervention

ED physicians might perform these counseling services for patients who they suspect of "drug seeking behavior," says Joan Gilhooly, president of Medical Business Resources in Barrington, Ill.

Example: A patient reports complaining of pounding headaches and says the only thing that relieves the pain is Vicodin. During the evaluation, the physician recognizes the patient is taking part in drug-seeking behavior and takes advantage of the opportunity to evaluate the patient.

You may be able to report an E/M service in addition to 99408 or 99409 if the ED physician provides one, according to Granovsky.

(For more information on documenting your alcohol/substance abuse screening claims, see the next story,"Let DAST Guide Your Counseling Claims.")