Primary Care Coding Alert

Question: A patient presents with an amputated finger from a work-related accident. At a walk-in clinic, a family physician injects lidocaine into the patient's finger, cleans the area and administers a tubular dressing. He also administers a tetanus shot. The physician spends a lot of time caring for the patient's injury. How should I code the services, procedures and/or supplies for optimum reimbursement?

Florida Subscriber

Answer: For the evaluation that the FP performed prior to treating the injury, you should report an office visit (99201-99215, Office or other outpatient visit for the E/M of a new or established patient ...). Select the level based on the history, examination and medical decision-making that the FP documents. Alternatively, if the FP documents that counseling comprises more than 50 percent of the visit, you may use time as the key element in determining the appropriate-level E/M service. Suppose your physician spends a lot of time talking with the patient about treatment options, amputation care and/or the consequences of no longer having a finger. He documents that he spends more than 50 percent of the visit counseling the patient. In this case, you may select the code level based on time and coordination of care.
 
If the FP performed a complex repair of the amputated finger, you should report the appropriate complex skin repair code(s) (13131-13133), reflecting the length of the repair. If you report a complex repair code in addition to the E/M code, you may need to add modifier   -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to reflect it was a significant, separately identifiable service.
 
You should bill individually for all supplies not otherwise included in the service codes reported, using either the appropriate HCPCS codes or CPT code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) with a description of each item. Check your state's workers' compensation guidelines for supply billing. Some states require the generic CPT code, while other states don't cover supplies. If your state permits supply billing, make sure to report the bandage materials (e.g., A6451 Moderate compression bandage ...), tape (e.g., A4452, Tape, waterproof, per 18 square inches) and surgical tray (A4550, Surgical trays).
 
Don't forget to code for the tetanus toxoid (90703, Tetanus toxoid adsorbed, for intramuscular use) and administration (90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]).