Urology Coding Alert

CMS wants you to meet 3 new G-codes - and reacquaint yourself with an old CPT Code - to report injections in 2005

If you code 90780, 90782 or 96400 for injection administration for Medicare patients in the New Year, you're likely to receive a pile of denials. That's because Medicare has introduced 3 new temporary G-codes to take their place for 2005.

You'll see slightly less reimbursement from the G-codes than you did from the CPT Codes - but you will be able to bill them with E/M services "with the expectation of full payment for both," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

Get to Know These 3 G-Codes

The Medicare Modernization Act (MMA) mandated an examination of drug administration codes to make sure they adequately reflect the work involved in the procedures. A Drug Administration Workgroup, made up of representatives from various specialties, including urology, suggested several coding changes. The CPT Editorial Panel accepted 12 new and 14 revised codes for drug infusion and administration - but they won't appear in CPT books until 2006. As a stopgap measure, CMS decided to use G-codes in 2005 for physicians billing Medicare for drug infusion and administration.

Urology coders, keep your eyes open for these new codes for use in the office:

For Zometa injections:

Old code: 90780 - Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour
 
2005 code: G0347 - Intravenous infusion, for therapy/diagnosis, initial, up to one hour

For therapeutic or diagnostic injections, such as Depo-Testosterone:

Old code: 90782 - Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular
 
2005 code: G0351 - Therapeutic or diagnostic injection.
 
For Lupron, Zoladex or other anti-neoplastic injections:
 
Old code: 96400 - Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia

2005 code: G0356 - Hormonal, anti-neoplastic, subcutaneous or intramuscular injection.

In the 2005 physicians' fee schedule, codes 90780, 90782 and 96400 are listed with a status code of "I." That status code indicates that the CPT codes are no longer valid for Medicare purposes, says Ann Helfenbein, CCS-P, coding specialist for the urology division of the Texas Tech University Health Sciences Center in Amarillo. Medicare uses other codes - in this case, the new G-codes - to report and pay services marked with an "I" status code.

Upside: Previously, 90782 had a "T" status code, which meant that Medicare would only pay for it if there were no other services payable under the physician fee schedule billed on the same date by the same provider.  

However, all the new G codes (including G0351, which replaces 90782) have an "A" status indicator - meaning you can always bill them separately.

Smart idea: Check with private and commercial carriers to see if they are continuing to use the older codes in 2005 or if they are converting to the new G codes. "I suspect, to remain in compliance with HIPAA, private and commercial carriers will eventually accept and use the G codes - and probably decrease their reimbursements for 2005," predicts Ferragamo.

Bid Farewell to G0001

After introducing those three new temporary codes, Medicare is deleting one: G0001 (Routine venipuncture for collection of specimen[s]) will be missing from the 2005 clinical laboratory fee schedule. In its place, you can now report 36415 (Collection of venous blood by venipuncture) for Medicare patients.

You'll still find a status indicator of "X" (Statutory exclusion) next to the code in the 2005 physicians' fee schedule, but this is an error, according to Medicare. "Code 36415 has now been activated to be payable by Medicare effective January 1, 2005," says CMS in a November 5, 2004 transmittal. "The HCPCS coverage indicator should be corrected to 'C' [Carriers price the code]." Check with your carriers to see how they'll reimburse for 36415.

Get Ready for a Dent in Drug Administration Pay

The decrease in reimbursement in 2005 is mostly due to the decrease in the transitional payment that MMA mandated for drug administration procedures. "The 32 percent transitional increase from 2004 has been decreased to a 3 percent transitional increase for this year," says Ferragamo.

Example: In 2004, 96400 had 1.30 relative value units (RVUs). Multiplying them by the 2004 conversion factor ($37.3374) and adding the 32 percent increase yielded $64.07 in unadjusted reimbursement. In 2005, G0356 has 0.94 RVUs; multiplying them by the 2005 conversion factor ($37.8975) and adding 3 percent yields only $36.69.

MMA also mandates a new payment system for the drugs themselves. Beginning January 1, drug payment will be 106 percent of the average sales price (ASP), says Ginger Cassity, CPC, billing manager at Northwest Urology in Fedway, Wash. Previously, CMS based payment on 85 percent of the average wholesale price (AWP) of the drugs, says Cassity. CMS will update the payments quarterly, with a two-quarter lag time; the payments for the first quarter of 2005 will be based on the ASPs from the third quarter of 2004.

Problem: CMS estimates that urology practices will see a 40 percent drop in Medicare drug revenue in 2005 as a result of switching to the new payment system, according to a statement by the American Urological Association. CMS expects to release the actual payment amounts for the first quarter of 2005 by mid-December, 2004.

Note: For more information on Medicare drug coding and pricing, visit www.cms.hhs.gov/providers/drugs/default.asp.