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Chapter 8

Medicine

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Introduction

Diagnostic, therapeutic, and


miscellaneous procedures and services
Health-care providers other than
physicians have unique service codes
Special service codes
i.e., outside of normal office hours

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Common Modifiers
-25
Separately identifiable evaluation and management
service by the same physician on procedure day
-50
Service code represents unilateral procedure, it is
provided bilaterally
-52
Services provided are less than the full code
describes
-59
Encounter has occurred on the same day and codes
have already been billed for those services
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Injections and Infusions:
Immune Globulins

Immune globulins provide protection


against certain diseases
Injections
Intramuscular
Subcutaneous
Intravenous

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Injections and Infusions:
Vaccination and Toxoid Administration
Immunity: body produces antibodies in response to antigen
exposure
Antigens: Bacteria, viruses, fungi
Route of administration
Percutaneous
Intradermal
Subcutaneous
Intramuscular
Intranasal
Oral
Age of patient
Number of administrations: Add-on codes for each additional
Two codes are required: Administration and vaccine or toxoid
product injected
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Injections and Infusions: Hydration
Hydration: administration of prepackaged
fluid and electrolytes (not drugs)
Codes are based on time
96360 one hour
96360 should not be used as the initial service if a
patient is also treated with a medication
Example: Patient with nausea and vomiting receives IV
fluids and then Phenergan IV push (through the IV).
Code Phenergan administration as the initial service and
fluids as 96360
96361 add-on for each additional hour

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Injections and Infusions

Therapeutic, prophylactic, and diagnostic


Codes based on route and time
First hour, each additional hour
Medication supply codes: depends on
payer requirements
Assign a J code from HCPCS Level II
If payer will not accept J code, assign 99070

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Injections and Infusions

Injection and infusion codes include the


following services:
Local anesthesia
Starting the IV
Establishing access to the IV (catheter or port)
Flushing of the line at the conclusion of
infusion
Supplies
Preparation of the substance(s) to be infused
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Injections and Infusions

Concurrent infusions: multiple substances


administered through one IV site but separate
bags
Piggybacking
Add-on code reported once per encounter
Modifier -59 used for second encounter
Intravenous and intra-arterial push
Codes only used when provider is present or infusion
takes less than 16 minutes
Code as subsequent if push is given after starting a
separate infusion (not initial service)
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Psychiatry
Codes are provided for inpatient and outpatient
services
Psychotherapy codes
Based on face-to-face time: may be reported by
psychologists, social workers, counselors
Health assessment and medication monitoring: must
be used by psychiatrist (or other physician), nurse
practitioner, or physician assistant
Family psychotherapy
Provided with or without patient present
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Dialysis Hemodialysis for ESRD
End-stage renal disease (ESRD): 15% of kidney function
remains
Hemodialysis: removes waste products of metabolism
from the bloodstream
Coding in the outpatient setting
One full month or per day services
Age
Codes include the following services:
Dialysis cycle
Care provided during visit
Evaluation and management services
Telephone calls relating to the care
Nutritional assessment and review, growth monitoring, and
parental counseling and support (if younger than 20 years)
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Dialysis

Coding in the inpatient setting for ESRD


and non-ESRD patients
If the physician is present during hemodialysis
(9093590940)
Peritoneal dialysis or services other than
hemodialysis (codes 9094590999)
Codes available for single evaluation or
repeated evaluations by physicians
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Gastroenterology

Gastroesophageal reflux disease (GERD)


Acid in esophagus, changes pH
Tests for pH
Manometric studies for motility
Capsule endoscopy: camera pill

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Ophthalmology

Ophthalmology: the study of the eye


9200292014 For new and established patients
Ophthalmoscopy and dilation of pupils not coded
separately
Examples of procedures that are coded:
Fluorescein angioscopy: determine the blood supply
to the retina
Tonography: determine pressure within the eye
Visual field testing: defects in the field of vision

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Otorhinolaryngologic Services

Otoscopy, rhinoscopy, hearing tests (using


tuning forks, whispered voices) are part of E/M
services routinely provided
Auditory rehabilitation: testing for hearing loss
and speech understanding
Codes are based on time: first code for 1 hour and
add-on code for each additional 15 minutes
Codes also provided for patients with hearing loss
before beginning speech and after learning speech

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Cardiovascular Services:
Electrocardiography

Tracing of the electrical activity in the heart


Physicians office procedures include:
Entire procedure
Provision of a tracing only
Provision of interpretation and report only
Holter monitor: portable device providing
24-hour tracings of electrical activity of the
heart
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Cardiovascular Services:
Echocardiography

Ultrasound of the heart chambers, valves,


great vessels
2D or Doppler
Complete or limited studies
Transthoracic
Transesophageal

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Cardiovascular Services:
Cardiac Catheterization
Component coding
One catheter placement code
All applicable injection procedure codes
Imaging supervision and interpretation
codes

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Cardiovascular Services:
Cardiac Catheterization
Procedures included in cardiac catheterization codes and
not coded separately
Catheter insertion (percutaneous or cut-down)
Positioning and repositioning of catheters
Injection of dyes (site of angiography)
Recording of intracardiac and intravascular pressures
Obtaining blood samples for gas analysis or dilution curves
Cardiac output measurements
Pharmacologic administration

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Cardiovascular Services: Percutaneous
Transluminal Coronary Angioplasty
(PTCA)
Percutaneous coronary intervention (PCI)
Used if blockage is found during catheterization
Coding for stenting
PTCA is not coded separately, catheterization is
coded separately
Stenting codes are assigned for each vessel
Multiple stents in one vessel is coded as one stenting
Coding for atherectomy
PTCA is not coded separately, catheterization is
coded separately
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Cardiovascular Services:
Electrophysiologic Procedures
Electrophysiologic studies (EPS) and mapping
Performed to determine the areas of damaged tissue
in the heart that cause arrhythmias
Atrial fibrillation
Ventricular tachycardia
Intracardiac catheter ablation is performed to
destroy the aberrant tissue
EPS, mapping, and ablation usually done on the
same day
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Pulmonary Services: Mechanical Ventilator
Device used to assist the patient with
breathing
Codes based on initial day or subsequent
day(s) and are provided for:
Inpatient services
Nursing homes
Rest homes
Assisted living
Home health visit code also available
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Pulmonary Services: Spirometry

Pulmonary function testing that measures


breathing mechanics
Code provided for before and after
bronchodilator treatment
Code 94070: multiple increasing dosages
of a treatment administered to determine
the effects of treatment in increments

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Allergy Services
Immunotherapy is treatment
Codes provided for testing by:
Percutaneous
Intradermal
Patch
Inhalation
Ingestion
Professional services: three coding scenarios
Physician prepares and provides the antigen to the
patient in a vial
Provider administers antigen (injection)
Physician both prepares and gives injections
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Neurology:
Sleep Studies (Polysomnography)
Sleep studies measure ventilation, respiratory effort,
electrocardiogram (or heart rate), oxygen saturation
Polysomnography testing includes:
Electroencephalography (EEG)
Electro-oculography (EOG)
Electromyography (EMG)
Additional variables monitored for sleep staging include:
Airflow
Respiratory effort
Gas exchange
Limb muscle activity
Extended EEG
Penile tumescence
Gastroesophageal reflux
Continuous blood pressure monitoring
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Neurology: EEG and EMG
Electroencephalography (EEG)
Records electrical activity in the brain
Recording time determines code
Used to determine brain death
Electromyography (EMG)
Records electrical activity in muscle(s)
14 extremities
Larynx
Hemidiaphragm
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Chemotherapy Administration
Services included in chemotherapy codes:
Local anesthesia
IV beginning and maintenance
Supplies
Preparation of chemotherapy agent(s)
Timing of services is important for correct administration
code assignments.
96413: assigned for the first hour
96415: add-on code for each additional hour
Separate codes are reported for each method of
administration
Incidental hydration administered with chemotherapy is
not coded separately

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Chemotherapy Administration
J codes provided in HCPCS Level II for
specific chemotherapeutic substances
If J codes are not accepted by the carrier, the supply
code (99070) should be used with specification of
agents received by the patient
Infusion pump
96520: refill services code
96414, 99211: continuous infusion for several days,
including pump initiation and disconnection (with no
refill)
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Physical Medicine and Rehabilitation
Physical therapy, occupational therapy, and athletic
training
Supervised modalities (reported one time per date),
direct contact with provider is not required:
Application of hot or cold packs
Mechanical traction
Electrical stimulation
Vasopneumatic devices
Paraffin baths
Whirlpool
Diathermy
Infrared
Ultraviolet
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Physical Medicine and Rehabilitation
Constant attention modalities the provider
cannot leave the patient (i.e., iontophoresis)
Codes represent 15 minutes of treatment time
Should not exceed increments of two per day
Therapeutic procedures
Given in 15-minute increments
Direct patient contact
Code 97150, assigned if two patients are being
supervised at once
Medicare does not consider more than 1 hour of
therapeutic services medically necessary
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Physical Medicine and Rehabilitation
Training for activities of daily living (ADL) are
coded in 15-minute increments.
Transfer techniques (on/off toilet)
In and out of shower or tub
In and out of bed to a chair
Meal preparation
Nutritional counseling
Ordered by a physician, provided by a registered
dietitian
Timed in 15-minute increments
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Physical Medicine and Rehabilitation:
Acupuncture and Chiropractic
Acupuncture: needles are inserted under the
skin
With or without electrical stimulation
Initial 15 minutes (only one initial code per session)
Each additional 15 minutes is coded with an add-on
Evaluation and management services reported
separately with modifier -25
Chiropractic manipulative services
Regions of the spine: Cervical, thoracic, lumbar,
sacral, and pelvic
If manipulation is performed on more than one
segment, count as one region adjusted
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Special Services, Procedures, and Reports
Handling a specimen that is sent to an outside
laboratory: 99000
Miscellaneous codes include orthotics and
prosthetics shipping for adjustments.
Physicians may include codes for services
provided after hours or on weekends or
holidays.
99058 may be added to the E/M code for service if a
patient is seen emergently in the office
99050 may be added if a patient is seen in the office
on a weekend when normally closed
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