Internal Medicine Coding Alert

Updating your encounter forms for next year won't take long, because few of the changes in CPT 2003 affect internists' offices.

The two main coding changes that may impact internists pertain to lesion removal and venipuncture. The only E/M code changes this year apply to pediatric critical care, an area that most internists don't address.

Internists who excise lesions should note a major change: You now will code bigger and reimbursement may get better.

"The change is in how we measure the lesion," says Arlene Morrow, CPC, CMM, president of AM Associates, a Tampa, Fla.-based coding and compliance consulting company.

CPT 2003 changes the 11400 series (Excision benign lesions) and the 11600 series (Excision malignant lesions), expanding the measured area to include not just the lesion but the margin as well.

"This is financially significant," says Jean Ryan-Niemackl, LPN, CPC, who is based in Fargo, N.D., as a content analyst in the HIM division of QuadraMed, a national healthcare information technology and consulting firm.

For example, a benign lesion that measures 2 centimeters under 2002 rules might measure 2.3 centimeters with the margin included for 2003. That boosts the procedure from a 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) to a 11403 ( excised diameter 2.1 to 3.0 cm), Ryan-Niemackl says.

The 2003 Physician Fee Schedule was not available as of press time. But using 2002 rates, that is a difference in reimbursement of $21, from $157.10 for 11402 to $178.10 for 11403, using national figures not adjusted for region.

CPT doesn't specify how large an area around the lesion should be removed, noting that "the margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment."

The last phrase in the description is important, Ryan-Niemackl says: "It says the physician is who judges what needs to be excised and, if it is an area larger than the lesion itself, the physician can feel comfortable billing for it."

Remind the physician to measure the lesion and the margin and record the total size prior to excision because you must know the size to select a code, she notes. If no size is recorded, you can find it in the pathology report, "but doing so puts your practice at a financial disadvantage because it is a well-known fact that lesions shrink when placed into formaldehyde," Ryan-Niemackl says. "Since codes are based on size and are separated by only 0.1 centimeter, it could mean being forced to select a lower code, which in turn could affect the reimbursement of your procedure."

If your office does finger, heel or ear sticks to draw blood, take note of a new code for 2003: 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]). Previously, CPT included these sticks with venipuncture in 36415, which now includes only collection of blood via a needle through a vein. Offices that do finger sticks to perform Coumadin monitoring on non-Medicare patients should be sure to note this change.

It may also signal that a bigger change is in store in Medicare coding. Medicare, which does not pay for finger/heel/ear sticks, created its own code for venipuncture (G0001) because 36415 covered these sticks in addition to venipuncture.

"Now that the AMA has created a separate code for venipuncture, my feeling is that Medicare will drop G0001 and go with the AMA code," says Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed, which is based in San Rafael, Calif.

She advises coders to keep a watch for this change in the new Medicare fee schedule, scheduled for release soon.

CPT 2003 makes some small alterations in the codes for muscle, tendon and joint injections. Previously, 20550* (Injection[s]; tendon sheath, ligament) and the 20600 series (Arthrocentesis, aspiration and/or injection ...) included ganglion cysts. Now there is a new code just for ganglion cysts, 20612 (Aspiration and/or injection of ganglion cyst[s] any location).

CPT also clarified trigger point injection codes 20552 and 20553, changing the language to specify injections in individual muscles rather than muscle groups, terminology that had confused some coders. (See injections story, this issue.)

Some internists use an ultrasound procedure, rather than the more invasive catheterization, to measure post-void residual urine in patients with urinary and incontinence disorders. Previously, G0050 was the code for this. Now, CPT 2003 creates a code for this procedure: 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging). Some coders expect Medicare to drop G0050 now, but check your 2003 Medicare Physician Fee Schedule to be certain.