Primary Care Coding Alert

The new Correct Coding Initiative edits are in, and family practice coders will need to watch out for several injection codes that have been bundled with almost every surgical procedure code in the book.

Last quarter's CCI edits gave FP coders a break, but this time around you'll have to make some adjustments. Code 36410* (Venipuncture, child over age 3 years or adult, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture), used frequently by FPs, is now no longer separately billable with most surgical procedures, including the maternity codes. For example, if the FP drew the patient's blood during a postpartum care period to check for anemia, do not code separately for 36410 report only 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). However, CCI indicated that under special circumstances these two codes will be paid separately if the proper modifier is appended.

CCI also bundled 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) with many other codes. If you are going to bill 90780 with a procedural service on the same day, you'll need to attach an appropriate modifier to get paid.

The same holds true for 36000* (Introduction of needle or intracatheter, vein) it too is bundled with a plethora of procedure codes. Among the relevant bundles is the maternity code 59400 as well as 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]). Potentially, an FP may have to start an IV while delivering a baby. Coders could only report 59400 or 59409 in this case, whereas before they may have reported 36000 as well. Like the others, the modifier exception applies to 36000 if the procedure is justifiably separate.

CMS also implemented edits to deny other E/M services (such as office visits, ER visits, etc.) done on the same day as an admission to observation status (99218-99220, 99234-99236), unless a modifier is used. This is generally consistent with current CPT rules stating that when a patient is admitted to observation from another site of service (such as the office or ER), only the observation admit is to be coded.

A modifier overrides the edit if, for example, the physician sees the patient in the office that morning for the flu, sends the patient home and then later that day has to admit the patient to observation because he developed a separate problem, such as chest pains. Or an FP may see a patient for asthma during an office visit, and later in the day she develops acute exacerbation and must be admitted to observation. In both cases, report the observation status code with the appropriate modifier attached, and the E/M visit separately. However, if the patient with asthma presented to the office with acute exacerbation and the FP admitted her, you would only use the observation status code.

The edits crack down on two new HCPCS codes: G0248 (Demonstration, at initial use, of home INR monitoring for a patient with mechanical heart valve[s] who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results and documentation of a patient's ability to perform testing) and G0250 (Physician review/interpretation and patient management of home INR test for a patient with mechanical heart valve[s] who meets other coverage criteria; per 4 tests [does not require face-to-face service]). Medicare will not pay for either of these codes done in conjunction with an office visit (99201-99215), outpatient or confirmatory consultation (99241-99245, 99271-99275), or nursing facility, domiciliary, or home visit service (99301-99350) provided to the same patient on the same date, unless an appropriate modifier is attached to the G code.

FPs may treat patients with mechanical heart valves to regularly manage their Coumadin and check their bleeding time with the INR test. G0248 is used when the physician first shows the patient how to use the monitor. CMS now says you will only be reimbursed for the G code for such visits. If the FP performs a clearly separate exam during the visit that would warrant charging an E/M code in addition, append the appropriate modifier to the G code. G0250 is used for the physician's interpretation of the INR results and does not require the patient's presence.

Although FPs would not be performing an E/M in most cases along with the INR interpretation, it is possible that another physician will request the FP to interpret INR as a consultation. In such a case, you have to append a modifier (e.g., -59, Distinct procedural service) to G0250 to get paid for the interpretation and consultation separately.

According to Medicare, CCI edits take precedence over any guidelines in CPT. Although private payers are not required to observe CCI edits, many do, either in whole or in part. Check with individual payers before billing.

Note: The CCI is available by subscription from the National Technical Information Service (NTIS) in print or as a CD-ROM in searchable (pdf) format. Contact NTIS for more information at (800) 363-2068.