Internal Medicine Coding Alert

These 3 must-have edits prepare you for strapping, nebulizer, E/M denials

No fooling: The new Correct Coding Initiative (CCI), version 14.1, went into effect April 1, and it contains bundles for I&D and continuous inhalation treatment -- as well as some new facility E/M edits.

Read on to find out what the experts say about when you can break these bundles, and when you need to let them be.

1. Include Applying Dressing in I&D

If your internist performs an incision and drainage (I&D) and then applies an Unna boot, you have to reduce your coding from two procedures to one. Bundling issues now exist on these procedures, says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop & Associates.

CCI 14.1 puts an end to coding the strapping (29580, Strapping; Unna boot) with an I&D. CCI version 14.1 edits bundle Unna boot strapping code 29580 into the following codes:

• 10060 -- Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

• 10061 -- ... complicated or multiple

• 10140 -- Incision and drainage of hematoma, seroma or fluid collection

• 10160 -- Puncture aspiration of abscess, hematoma, bulla, or cyst

• 11000 -- Debridement of extensive eczematous or infected skin; up to 10% of body surface.

Consider this example: An established patient with a small abscess reports to the internist. The internist performs I&D on two cysts on the patient's lower left leg. To help the wounds heal, the internist applies a knee-to-foot Unna boot.

CCI 14.1 restricts the use of codes 10060 and 29580 together. According to the edit, 10060 is the column 1 code and 29580 is the column 2 code. This means that on the claim, you should report 10060 for the services with 682.6 (Other cellulitis and abscess; leg, except foot) appended to represent the patient's injury.

Exception: You may, however, report an Unna boot strapping with the above codes in some situations.

"The edits permit you to use modifier 59 (Distinct procedural service) to break the bundle under extenuating circumstances, such as different anatomical sites, supported with documentation," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Note: For some payer policy information on Unna boot coding, see "This FAQ Gives You Unna Boot Ins and Outs" on page 45.

2. Use Time to Choose Inhalation Code

Coders should also be aware of one new bundle on inhalation treatments. Do not report an individual inhalation treatment, such as with a nebulizer, in addition to continuous inhalation treatment.

CCI 14.1 makes inhalation treatment codes 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and 94642 (Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis) components of the more extensive procedure 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour).

Warning: The edits do not allow you to override the bundle under any circumstances. Choose the correct code based on time following these guidelines:

• Use 94640 for intermittent inhalation treatment.

• Restrict 94644 only to procedures lasting 60 minutes, according to Medical Learning Inc.'s respiratory compliance experts.

3. Keep Coding Modifier 25 Service

The next time a patient requires hydration therapy or therapeutic injection following an E/M service, your procedure pay may depend on modifier 25 (Significant, separately identifiable E/M ...), thanks to a new batch of edits.

CCI 14.1 extends the intravenous infusion (90760, 90765) and therapeutic, prophylactic or diagnostic injection (90772-90774) E/M bundles to the facility setting.

Version 14.1 includes intravenous infusion (90760, 90765) and therapeutic, prophylactic or diagnostic injections (90772-90774) in all facility and home E/M services (99217-99350). CCI 12.0 had made 90760, 90765 and 90772-90774 components of office-based E/Ms.

CMS bases the injection-inpatient/observation edits on "standards of medical/surgical practice" and allows a modifier breaker. The edit simply codifies an already present CPT guideline.

The Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy) introductory notes state, "If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Relief: The new edit doesn't change much, Merrill says: "These services have been bundled together since the creation of 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular)."