The ins and outs of billing for procedures Fail to link a procedure code to a diagnostic one, and you may be setting yourself up for an audit by Tamra McLain, CPC, CPC-H, CMC
Published in the October 2007 issue of Today's Hospitalist
When it comes to doing procedures, where you practice has a lot to do with what procedures you may be billing for and performing.
Hospitalists who practice in rural hospitals, for instance, probably do a high volume of procedures because specialists are few and far between. Physicians in major urban facilities, on the other hand, may do only a few—even though hospitalist groups in major academic centers are finding that procedure services can bring in good revenue.
When you bill for any type of procedure, keep this rule of thumb in mind: You need
Some procedures done during critical care, such as gastric intubation, should not be reported separately.
to choose the right ICD-9 codes to show medical necessity. If you’re performing an incision and drainage on an abscess, be sure to report a cellulitis diagnosis, for instance, and link that ICD-9 diagnosis code to the CPT code you report for the procedure.
If you fail to make that correlation, you can expect questions from payers, and potentially set yourself up for an audit. Here’s a look at common procedures along with their codes and criteria.
Incision and drainage (I&D)
When choosing the right code for an incision and drainage, start with a simple question: What needs to be incised? CPT breaks this code series down into the following categories:
• 10060-10061: incision and drainage of abscess. You would use one of these two codes for the I&D of a carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia.
In the case of a simple incision that you’re leaving open to drain on its own, use 10060. If you need to pack the incision or make multiple incisions, use 10061 to describe the additional work.
• 10080-10081: incision and drainage of pilonidal cyst. If the cyst is left to close on its own, use the 10080 code to bill for this “simple” procedure. If the wound requires tissue excision, primary closure or even Z-plasty, choose the “complicated” CPT code of 10081.
• 10140: incision and drainage of hematomas, seroma or fluid collection. Use this one code, regardless of whether you leave the wound open or closed. By the same token, use this same CPT code whether or not you use packing.
• 10180: incision and drainage of complex wound. Use this code when you have to remove staples or sutures or make an additional incision. You also use this code if you need to drain the wound or excise tissue, whether or not you pack the wound or leave it open for continuous drainage.
Thoracentesis and chest tubes
For patients who need an initial or subsequent thoracentesis for aspiration, report 32000. If you follow the thoracentesis with a tube insertion, such as for pneumothorax, then use 32002.
You may also need to place a chest tube if a patient is suffering from abscess, hemothorax or empyema. In those cases, code 32020.
Arterial and venous access
Vein sticks are coded as 36000: introduction of needle or intracatheter, vein. Use this code when you need to start an IV because a nurse is having trouble placing one.
Use 36620 when doing an arterial line for sampling or monitoring. If, however, you’re doing a cut-down procedure to obtain access for the arterial line, then use 36625.
There are several codes that pertain to central venous catheters. The one you choose depends on the patient’s age and whether or not the procedure requires tunneling to access the vein.
Here’s a breakdown of codes related to placing central venous catheters:
36555: patients less than age5, non-tunneled;
36556: patients age 5 and older, non-tunneled;
36557: patients less than age 5, tunneling required; and
36558: patients age 5 and older, tunneling required.
When removing a central line, use the code 36589.
When a patient has a fever of unknown etiology with neck pain and headache, you might perform a diagnostic lumbar puncture.
You would code that procedure as 62270. If you do a bad draw that obtains blood rather than spinal fluid, you’ve still met the requirements of the puncture and can bill the same code.
Hospitalists may perform many more procedures. According to the CPT manual published by the AMA, “Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health professional.”
When delivering critical care during the same session as a procedure, be sure to deduct the time spent doing the procedure from the time you report spending on critical care. Some procedures—IV access, gastric intubation and ventilator management, to name a few—are considered an inherent part of critical care and should not be reported separately.
And finally, it’s quite common to perform an evaluation and management (E/M) service on the same day as a procedure. When that is the case, you must modify the E/M code that you report with the -25 modifier to indicate that it was a separate, identifiable and distinct service. Otherwise, payers will bundle the two together, denying you payment for the E/M service you performed.
Tamra McLain is an independent coding consultant in Southern California. E-mail her your documentation and coding questions, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.