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Medicine
Chapter 8
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
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
Injections and Infusions:
Immune Globulins
• Immune globulins provide protection
against certain diseases
• Immune globulin administration (90765–
90775)
– Intramuscular
– Subcutaneous
– Intravenous
Injections and Infusions:
Vaccination and Toxoid Administration
• Immunity: body produces antibodies in response to antigen
exposure
– Antigens: Bacteria, viruses, fungi
• Route of administration
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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
Injections and Infusions:
Hydration
• Hydration: administration of prepackaged
fluid and electrolytes (not drugs)
– Codes are based on time
• 90760 – one hour
– 90760 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 90761
• 90761 – add-on for each additional hour
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
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
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)
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
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)
Dialysis
• Coding in the inpatient setting for ESRD
and non-ESRD patients
– If the physician is present during hemodialysis
(90935–90940)
• Peritoneal dialysis or services other than
hemodialysis (codes 90945–90999)
• Codes available for single evaluation or
repeated evaluations by physicians
Gastroenterology
• Gastroesophageal reflux disease (GERD)
– Acid in esophagus, changes pH
– Tests for pH
• Manometric studies for motility
• Capsule endoscopy: “camera pill”
Ophthalmology
• Ophthalmology: the study of the eye
– 92002–92014 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
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
Cardiovascular Services:
Electrocardiography
• Tracing of the electrical activity in the heart
– Physician’s 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
Cardiovascular Services:
Echocardiography
• Ultrasound of the heart chambers, valves,
great vessels
• 2D or Doppler
• Complete or limited studies
• Transthoracic
• Transesophageal
Cardiovascular Services:
Cardiac Catheterization
Component coding
– One catheter placement code
– All applicable injection procedure codes
– Imaging supervision and interpretation
codes
Cardiovascular Services:
Cardiac Catheterization
Procedures included in cardiac catheterization codes and
not coded separately
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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
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
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
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
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
Allergy Services
• Immunotherapy is treatment
• Codes provided for testing by:
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–
–
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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
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:
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Airflow
Respiratory effort
Gas exchange
Limb muscle activity
Extended EEG
Penile tumescence
Gastroesophageal reflux
Continuous blood pressure monitoring
Neurology:
EEG and EMG
• Electroencephalography (EEG)
– Records electrical activity in the brain
– Recording time determines code
– Used to determine brain death
• Electromyography (EMG)
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Records electrical activity in muscle(s)
1–4 extremities
Larynx
Hemidiaphragm
Chemotherapy Administration
• Services included in chemotherapy codes:
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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
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)
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:
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Application of hot or cold packs
Mechanical traction
Electrical stimulation
Vasopneumatic devices
Paraffin baths
Whirlpool
Diathermy
Infrared
Ultraviolet
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
Physical Medicine and
Rehabilitation
• Training for activities of daily living (ADL) are
coded in 15-minute increments.
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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
Physical Medicine and
Rehabilitation:
Acupuncture and Chiropractic
• Acupuncture: needles are inserted under the
skin
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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
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