Internal Medicine Coding Alert

Lump B-12, Rocephin and penicillin into 90772, regardless of payer

You can stop denials for 90782, 90788 and G0351 dead in their tracks--if you know the ropes of the 2006 coding method the new year will usher in.

Old way: In 2005, Medicare issued a temporary G code to replace CPT's therapeutic injection code. So to report administration of a B-12 injection (J3420, Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg), you would report G0351 for Medicare carriers and 90782 for private insurers.

New way: CPT 2006's introduction of one new injection code (90772) ends the dual reporting that therapeutic injection services require and counts antibiotic injections as the same procedure.

1. Use 90772 Instead of 90782, 90788, G0351

Effective Jan. 1, you should replace three injection administration codes (90782, 90788 and G0351) with a single new code (90772). CPT 2006 deletes:

• 90782--Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular

• 90788--Intramuscular injection of antibiotic (specify).

HCPCS 2006 should also delete:

• G0351--Therapeutic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

New method: Instead of choosing between 90782, 90788 and G0351 for injection administration, you should use a single code, 90772, Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

Important: Although 90772's descriptor doesn't specify "antibiotic," you should use the new code to report injection administration of an antibiotic. CPT added the directive in a small indentation at the end of the "Therapeutic, Prophylactic, and Diagnostic Injections and Infusions" subsection, says Christine DuBois, CPC, president for 2005 of Pioneer Valley Coders and coding/compliance coordinator at Western Mass Physicians Associations in Chicopee.

CPT's notes state, "90788 has been deleted. To report, use 90772." Because CPT 2006 lumps therapeutic, prophylactic, diagnostic and antibiotic injections together, "coders should have a simpler time coding injection administration," she says. You no longer have to determine whether to classify a particular drug, such as Rocephin (J0696, Injection, ceftriaxone sodium, per 250 mg), as 90782 or 90788.

Advanced coders should be able to determine which drugs fall under antibiotics when using 90788. "But using two separate codes for basically the same procedure isn't really necessary," DuBois says. The J code identifies which drug the nurse injects.

How it works: An internist gives a penicillin shot to a patient with an upper respiratory infection. You would now have to identify penicillin (such as J0530-J0580, Injection, penicillin G benzathine ...) as an antibiotic to realize you should use 90788 instead of 90782. In 2006, you'll just have to remember to assign new code 90772.

2. Verify Admin Meets Direct-Supervision Criteria

Before using 90772, make sure an internist provides direct supervision throughout the procedure. CPT adds this requirement in an instruction following 90772 that indicates you should "not report 90772 for injections given without direct physician supervision."

If the injection administration encounter does not meet the direct-supervision criteria, you should instead report 99211, according to CPT's instructions following 90772. The directive indicates that "CPT has adopted CMS' direct-supervision guidelines as defined in the Medicare Carriers Manual 2050.1," says Quinten A. Buechner, MS, MDiv, CPC, president of ProActive Consultants LLC in Cumberland, Wis.

Translation: The physician must be in the office setting and immediately available. The requirement does not mean the internist must be present in the exam room during the procedure to bill for 90772, Buechner says. "This level is higher than the general-supervision [physician available by phone] requirement that shots, such as B-12 injections, require in 2005."

3. Research Insurers' Incident-to Policies

When a nurse provides injection administration under general supervision, you should report 99211 instead of 90772--provided the procedure meets payers' incident-to rules. "You should check a company's incident-to rules before using 99211 without direct physician supervision," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Example: A patient who has a standing order for B-12 injections comes into the office in the morning for his injection. The internist is at the hospital making rounds.

In this situation, you should use 99211 instead of 90772, according to CPT rules. The procedure does not meet the direct-supervision requirement because the physician is not present in the office suite.

But CPT's 99211 directive could contradict insurers' incident-to requirements. "Although some payers follow CPT's more liberal rules and allow 99211 without direct supervision, CMS requires the physician provide direct supervision to bill a service incident-to," Cobuzzi says.

The lowdown: Reporting 99211 for the above B-12 injection scenario hinges on the insurer's incident-to requirements. "If the patient is a Medicare patient, you should treat the injection as a no-charge service," Cobuzzi says. You would code neither 90772 nor 99211. Report the B-12 product with J3420.

4. Prove MD's Presence Using This Tool

The direct-supervising internist does not have to be the physician who created the standing order. But to avoid 90772 repayments, make sure documentation can prove the physician's presence.

Best practice: "Have a stamp made that indicates 'Supervising physician present,' " Cobuzzi says. The nurse can then write which doctor was present during the injection administration. If Medicare requests documentation supporting direct supervision or audits your 90772 claims, the chart note will substantiate your charge.

The scheduling record should also show which doctor was present in the office during the injection administration.

5. Understand CMS Expected CPT to Replace G0351

Although re-educating staff on injection administration coding on the heels of 2005 changes may seem frustrating, this new method should apply long-term. Medicare created G0351 because the replacement CPT code was unavailable in 2005.

Medicare issued the medicine G codes to comply with the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which required a review of the current codes. "The AMA's CPT Editorial Panel revamped the codes" but didn't complete the changes in time to include the new codes in CPT 2005, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa.

Instead of waiting until 2006 for the revamped CPT codes, "CMS (Medicare) felt it was necessary to incorporate the changes for 2005," Falbo says. Now that CPT 2006 codes exist, you should use these codes for all insurers.