Pediatric Coding Alert

This action plan will make your Rocephin, Decadron claims shine.

Although therapeutic injections are claiming the spotlight in 2009, the added attention isn't necessarily a good thing. Your 90772 claims can win coding and compliance gold stars if you follow these rules presented at the 2008 American Academy of Professional Coders conference in Orlando.

Stick to 90772 When MD Is Present

The first guideline you have to adhere to when reporting therapeutic injections is to reserve 90772 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for direct supervision cases. Code 90772 requires direct supervision during the injection's administration, relays Robin Linker, CPC, CPC-H, CCS-P, MCS-P, CPC-P, RMC, CHC, in "Targets and Pitfalls in Primary Care Coding." When the administration involves no direct physician supervision, meaning the physician is not in the office suite, use 99211 (Office or other outpatient service for the evaluiation and management of an established patient, that may not require the presence of a physician ...  typically, 5 minutes are spent performing or supervising these services).

Example: A mother brings her baby in for her first Rocephin injection while the pediatrician is in the office. The baby receives her second and third doses when the pediatrician is on her lunch hour off-premises. You should use 90772 for the first injection and 99211 for the subsequent injections, Linker says.

CPT's note following 90772 instructs you to use 99211 when there is no supervision. For malpractice protection, the AMA doesn't want a nurse injecting a patient when a physician isn't present, Linker explains.

Best practice: Check your major payers' policies and your internal operations, and see what Medicaid wants, Linker suggests. "This is a federal policy, which is subject to payer interpretation."

Code 99211 is typically associated with incident to billing which requires direct supervision.

Indicate Drug in Note
 
If an insurer requests documentation for your 90772 claims, you can expect them to search for one detail -- the name of the drug injected. Identify the injectable product in your 90772 documentation. The drug code, such as J1100, Injection, dexamethasone sodium phosphate, 1 mg) for Decadron or J0696 (Injection, ceftriaxone sodium, per 250 mg) for Rocephin, typically also represents a billable service if the practice purchases the product.

The 2007 Comprehensive Error Rate Testing (CERT) program found 76 percent of claims reviewed involving J1040 (Injection, methylprednisolone acetate, 80 mg) did not provide supporting documentation for the drug being given, reports Bruce Rappoport, MD, CPC, CHCC, in the AAPC's conference session, "Compliant Coding Working Within the 2008 OIG Work Plan." "There was no documentation verifying the use of methylprednisolone acetate provided for review," he says. For instance, the provider indicated he provided no such service or failed to produce a record.

Studying the work plan tells us where carriers are going to be looking for trouble spots. This in turn trickles down to private payers.