Internal Medicine Coding Alert

Codes for physical medicine therapeutic procedures and a visual acuity exam are among the new additions to CPT 2001 that may be reported by internists. There are also new codes for active wound care management and medical nutrition that internists may be tempted to bill, but should be reported only by nonphysician practitioners. Finally, revisions to the dialysis subsection of CPT 2001 further explain the use of these codes.

Cognitive Skills and Sensory Integrative Techniques

New codes for cognitive skills development and sensory integrative techniques have been added to the physical medicine and rehabilitation subsection of CPT 2001. These codes may be billed by an internist or therapist and require direct (one-on-one) contact with the patient. The new definitions and their new relative value units (RVUs) are as follows:

97532 development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes 0.68 RVUs; and

97533 sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes 0.74 RVUs.

The circumstances under which an internist should report these codes is the coding challenge, says Linda Botten, OTR/L, CHT, ATP, president of Montana Rehabilitation Therapy in Bozeman, Mont., and a member of the CPT Health Care Professionals Advisory Committee, in remarks she made as a presenter at the November CPT 2001 Coding Symposium sponsored by the American Medical Association (AMA).

There are three categories of cognitive impairment: attentional, short-term memory and problem-solving. Cognitive skills training allows individuals with these types of impairments to live independently, return to work and function safely in their environments. Patients with diagnoses such as psychiatric disorders, brain injury and cerebral vascular accidents may require these services.

Sensory integrative techniques are used with patients who have difficulty processing sensory information to make adaptive responses. Indications of sensory integrative impairment include:

anxiety and/or fear related to movement;
poor motor planning, excessive clumsiness, awkward movements;
poor postural responses;
poor coordination of bilateral movements; and
hyper/hyposensitivity.

These treatments are often used on pediatric patients, according to Botten. Common diagnoses for this treatment include autism, developmental disorders, attention deficit disorders, cerebral palsy and motor apraxia.

Codes 97532 and 97533 are timed, based on 15-minute intervals. According to Botten, however, Medicare has stated that the internist has to provide therapy for only half of that interval, eight minutes or more, to report the code. Less than eight minutes, and Medicare wont count it, Botten explains. She adds that 97001 (physical therapy evaluation) may be used to report an evaluation session that occurs before the start of therapy.

New Code for Visual Function Screening

Another new code in the physical medicine section that could be reported by internists is for visual function screening:

99172 visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination[s] for contrast sensitivity, vision under glare) 0 RVU.

This code will be used by internists more than ophthalmologists, said Stephen S. Lane, MD, clinical professor of ophthalmology at the University of Minnesota, in remarks he made as a presenter at the AMAs recent CPT 2001 Coding Symposium. The difference between 99172 and pre-existing 99173 (screening test of visual acuity, quantitative, bilateral) is that 99172 tests ocular alignment, color vision, field vision, and determination for contract sensitivity and vision under glare, in addition to visual acuity. It can be used by internists to test patients who work in an occupation (such as firefighter, nuclear power plant operator and heavy-equipment operator) in which optimal vision is important and standards for vision exist.

New Wound Care Codes for Nonphysicians

There are also code additions in the physical medicine section that should be reported only by nonphysician and other healthcare professionals. Because these codes also describe services provided by internists, internal medicine practices could easily confuse these nonphysician codes with their physician-provided counterparts.

There are two new codes for active wound care management:

97601 removal of devitalized tissue from wound; selective debridement, without anesthesia (e.g., high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 1.03 RVUs; and

97602 non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instructions(s) for ongoing care, per session 0 RVUs.

These codes are to be reported by nonphysician professionals licensed to perform these procedures, said Helene Fearon, PT, co-owner of Fearon Physical Therapy in Phoenix and a member of the AMAs CPT Editorial Panel, at the recent CPT 2001 Coding Symposium. Internists performing wound debridement should continue to report 11040-11044 (debridement; skin). Also, these new codes should not be reported in addition to 11040-11044. If an internist sees a patient and has the nurse change the dressing, the physician may think that he or she can bill the nonphysician wound care codes to get reimbursed for the changing of the dressing, but thats not allowable.

Who Should Bill New Nutrition Therapy Codes?

In addition, CPT 2001 includes the following new codes for nutrition therapy:

97802 medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 0 RVUs;

97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 0 RVUs;

97804 group (2 or more individual[s]), each 30 minutes 0 RVUs.

These codes are intended for use by dieticians, not physicians. A cross-reference after these definitions in CPT 2001 states that medical nutrition therapy assessment and/or intervention performed by a physician should be reported with an evaluation and management code or a preventive medicine service code.

Revisions Explain Reporting Requirements

In addition to new codes, CPT 2001 contains revisions to the introductory notes in the dialysis subsection, which further explain the appropriate use of the dialysis codes.

1. Codes 90918-90921 are reported once per month to distinguish age-specific services related to the patients end-stage renal disease (ESRD) performed in an outpatient setting. ESRD-related physician services include establishment of dialyzing cycle, outpatient evaluation and management of the dialysis visits, telephone calls and patient management during the dialysis, provided during a full month. These codes are not used if a hospitalization occurred during the month.

2. Codes 90918-90921 do not include the dialysis treatment (90935, 90937, 90945, 90947) or any non-ESRD-related services or other patient care services rendered outside of the dialysis setting during that month.

3. Evaluation and management services unrelated to ESRD services that cannot be performed during the dialysis session may be reported separately.

4. Codes 90922-90925 are reported when outpatient ESRD-related services are not performed consecutively during an entire month. Codes 90922-90925 are used to report ESRD-related services on a per-day basis for the remaining days of that month, preceding and/or following the period of hospitalization.

For example, a 4-year-old receiving continuous peritoneal dialysis has 16 days of daily outpatient care, preceding or following a period of hospitalization. The internist should report 90923 for each date outpatient care was performed. For ESRD-related services and dialysis procedure(s) performed during a period of hospitalization, report the appropriate inpatient evaluation and management code(s) for the hospitalized period if service(s) is unrelated to ESRD services. Report 90945 or 90947 for each inpatient dialysis procedure.

Although the new CPT codes and revisions are effective as of Jan. 1, 2000, there is a three-month grace period before the new codes must be used. Therefore, internists should contact their payers to determine when they plan to adopt the CPT coding changes and update their systems.