EM Coding Alert

A physician sees a nursing facility patient in the office due to severe hip joint pain. The doctor evaluates the patient and performs an x-ray. When the physician determines there’s no fracture, he decides to treat the joint pain with a 40 mg injection of Depo-Medrol.

 

You’re unaware that the patient is an NF resident in a Part A stay, so you report the office visit, the global x-ray code, the joint injection code, and the medication to the patient’s Medicare Part B carrier.

Since this patient is a nursing facility resident in a Medicare Part A nursing facility stay, the carrier will deny part of your claim, likely using denial code 190 (Payment is included in the allowance for a Skilled Nursing Facility [SNF] qualified stay). Medicare will not pay you for the technical component of the x-ray or for the Depo-Medrol medication used in the injection, because it will pay the nursing facility for those components under the consolidated billing guidelines.

 

For a Part A-covered patient in this scenario, you should report the office visit (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...), the injection (20610, Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), and the professional component of the x-ray service using modifier 26 (Professional component) to your Part B carrier.

 

“If the physician wants to be reimbursed for the technical component of the x-ray and the medication, she needs to have a contractual relationship with the nursing facility to provide — and be paid — for these services,” Gilhooly explains. When I’m advising a physician on what price to recommend to the nursing home, I suggest that they shouldn’t ask for more in a reimbursement than what they would get from Medicare, if they could bill Medicare for the services. In other words, look in the Medicare Physician Fee Schedule database for the reimbursement rate for the technical component of the x-rays they perform.  And look at the fee schedule for injectable medications to obtain the Medicare allowed amount for the medications they use.”