1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 30 MEDICINE

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Medicine Section Diagnostic and Therapeutic Procedures Most procedures noninvasive (not entering body) Contains invasive procedures –Example: 92973, Percutaneous transluminal coronary thrombectomy Numerous notes throughout

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Subsections Wide variety of services Many specialized tests –Example: Audiology Biofeedback

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Immunizations Often used Two types of immunizations –_____ and ______ Correct coding includes –_____ injected –____________ of injection Active passive Supply Administration (Cont’d…)

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Active—Bacteria or Viruses (…Cont’d) Bacteria that cause disease made nontoxic (_____) –Injected to build immunity Small dose active virus injected (______) –Injected to build immunity Example: Poliovirus (Cont’d…) toxoid vaccine

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Passive Immunization (…Cont’d) Does not cause immune response Contains antibodies against certain diseases—immune _______ globulins

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Immune Globulins (90281-90399) Identifies immune globulin product –Example: Botulism antitoxin Report ___________ separately (Cont’d…) administration

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Immune Globulins (90281-90399) (…Cont’d) Codes divided by: –Type e.g., Rabies, hepatitis B –Method e.g., Intramuscular, intravenous, subcutaneous –Dose e.g., Full dose, mini-dose From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders.

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Immunization Administration for Vaccines/Toxoids (90460-90474) Administration (performing the injection) of substance –Reported with substance given (Cont’d…)

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Immunization Administration for Vaccines/Toxoids (90460-90474) (…Cont’d) _____, 90461 Patients through age 18 when physician counsels regarding immunization 90471-90474 = Patients __ years of age or over –Patients of all ages (including under 19) if physician does not _______ regarding immunization _____, +90472 = Percutaneous, intradermal, subcutaneous, or intramuscular injection 90473, +90474 = ____ or intranasal 90460 19 counsel 90471 Oral

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Methods of Administration Percutaneous –Intradermal –Subcutaneous –Intramuscular Intranasal Oral From Bonewit-West K: Clinical Procedures for Medical Assistants, ed 8, St. Louis, 2012, Saunders.

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Report Administration for Each Dose—Single or Combination Example: Patient (over age 8) receives three separate administrations: 90471 tetanus 90472 rubella (add-on code) 90472 diphtheria (add-on code) –OR depending on payer: 90471 tetanus 90472 x 2 rubella and diphtheria

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vaccines, Toxoids (Vaccine Product Codes) (90476-90749) Many codes age specific –Example: 90658, trivalent influenza virus vaccine, for ages _ and over Codes for products for single diseases –Example: 90703, _______ toxoid Codes for combination of diseases –Example: 90700, diphtheria, tetanus, and acellular pertussis (_____) Caution: There are numerous code combinations of diphtheria (Cont’d…) 3 tetanus DTaP

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vaccines, Toxoids (…Cont’d) Some vaccines given on schedule –Example: 90634, 2-dose hepatitis _ vaccine –First dose, first visit –Second dose, second visit 90634 is reported for each visit A

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Remember Do not assign modifier ___ with Vaccine/Toxoid codes –Rather, depending on payer: List each code multiple times or Use times (×) symbol and indicate number Modifier -51 should not be reported for the vaccines, toxoids when performed with these administration codes (90460-90474) -51

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Important Reporting Rules If vaccine administered during office visit (not related to E/M) –Report E/M service (with modifier ___) + Vaccine + administration Depends on local carrier Office visit for vaccine only, code only ______, NO ____ service –Depends on local carrier -25 vaccine E/M

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Routine Vaccinations Influenza –Administration ______ HCPCS (Medicare only) 90471/_____ –Substance (trivalent influenza virus vaccine) 90657, _____ Pneumococcal –Administration ______ HCPCS (Medicare only) 90471/90472 administration –Substance (vaccine) _____ 90658 G0008 90472 90732 G0009

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Psychiatry (90785-90899) Psychiatric treatment at same time as E/M service, report –One code for therapy with E/M –Example: 90833, psychotherapy and E/M ____ major billing factor –Codes divided on time –Medical record indicates session time (Cont’d…) Time

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. When selecting a psychotherapy code ask these questions: 1.How much face-to-face time is spent with the patient? 2.Does documentation support an evaluation & management code in addition to psychotherapy? 3.If rendering psychotherapy, is the approximate “time” of the psychotherapy noted in the medical record? Psychiatry (90785-90899) (Cont’d…) (…Cont’d)

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Psychiatry (…Cont’d) Many services provided in partial hospital settings –Patient in hospital during day, returns to home for evenings and weekends Interactive psychotherapy is typically furnished to children –It uses play equipment, physical aides, nonverbal communications, or other mechanisms of communication

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Biofeedback (90901, 90911) Used to help patients gain control over body processes –Example: High BP or chronic pain Medicare Coverage Issues Manual 35-27 restricts the use of biofeedback Medicare doesn’t cover biofeedback for psychosomatic disorders (Cont’d…)

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Biofeedback (…Cont’d) Patient training in biofeedback by professional –Continues on own Services often part of _______________ (mind/body) therapy psychophysiologic

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Dialysis (90935-90999) Cleanses blood –________ (non-ESRD) –_________ (ESRD) Two parts to report ESRD dialysis services: –________ service –___________ procedure Patient receiving hemodialysis. (From Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera IM: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, ed 8, St. Louis, 2011, Mosby.) Temporary Permanent Physician Hemodialysis Figure: 30.4

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. End Stage Renal Disease Services (90951- 90970) Include –Establishment of dialyzing ____ –________ services –E/M ________ dialysis visits –Patient ___________ during dialysis Reported for month: 90951-_____ –Less than full month of service: ___________ per day –Codes divided on ___ and number of visits cycle Physician outpatient management 90966 90967-90970 age

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hemodialysis Service (90935-90940) Hemodialysis is the procedure –Used for ESRD and non-ESRD Billed ______ for inpatients receiving ESRD + non-ESRD Includes all physician E/M services related to procedure –Use modifier ___ if separate E/M service provided per day -25

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Miscellaneous Dialysis Procedures (90945-90947) Describes other dialysis procedures –Example: ________ dialysis in which toxins are passively absorbed into dialysis fluid (Cont’d…) Peritoneal

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Peritoneal Dialysis Services billed on per day basis for inpatient ESRD patients (…Cont’d) From Goldman L, Ausiello D, editors: Cecil Textbook of Medicine, ed 22, Philadelphia, 2004, Saunders.

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Dialysis Training Patients can receive training in self-dialysis –Reported with _____, 90993 –Codes divided by ________ or partial training program 90989 complete

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Gastroenterology (91013-_____) For tests and treatment of _________, stomach, and _______ Codes usually reported with ___ or __________ service code Caution: Many bundled services 91299 esophagus intestine E/M consultation

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Ophthalmology (92002-92499) Contains E/M codes –Not E/M codes from front of CPT Definitions for new and established patients same as for ___ section Most codes are for _______ services –If only one eye, use modifier ___ (reduced service) Read the definitions of intermediate and comprehensive services in the CPT! E/M bilateral -52 (Cont’d…)

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Example, Intermediate: Review of history, external examination, ophthalmoscopy, biomicroscopy for an acute complicated condition (e.g., iritis) not requiring comprehensive ophthalmological services Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision making cannot be separated from the examining techniques used Ophthalmology (92002-92499) (…Cont’d)

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Special Otorhinolaryngologic Services (92502-92700) For special evaluations of audiologic system Go beyond those usually provided in evaluation May be reported in addition to basic audiologic service (Cont’d…)

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Special Otorhinolaryngologic Services (…Cont’d) Special treatments and diagnostic services –Example: Nasal function tests (_____________) or audiometric tests All hearing tests _______ unless indicated one ear in description Use modifier -52 for 1 ear Nasal function test equipment. (From Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, Thomas JR: Cummings Otolaryngology-Head & Neck Surgery, ed 5, Philadelphia, 2010, Mosby.) Audiometric equipment. (From Proctor DB, Adams AP: Kinn's The Medical Assistant: An Applied Learning Approach, ed 12, St. Louis, 2014, Saunders.) rhinomanometry bilateral

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coronary Therapeutic Services and Procedures PTCA (92920-92921) –Access through the ______ or brachial artery –_______ with balloon tip threaded up to heart Balloon is expanded and widens vessel If an angioplasty and an artherectomy are performed during the same session, only the athrectomy is billed If a stent is placed in a coronary vessel, the stent placement takes hierarchy over the artherectomy Stent(s) placement(s) includes coronary angioplasty when performed (92928, 92929) femoral Catheter

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiography (93000-93278) Implantable and Wearable Cardiac Device Evaluations (93279-93299) And Echocardiography (93303-93352) –Reviewed in Chapter 21 of this text

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiac Catheterization Diagnostic medical procedure Three components included in most Cardiac Cath Codes: –____________ –_______ Congenital cardiac cath codes (93530-93533) do not include injection or imaging Reviewed in Chapter 21 of text Catheterization Injection Imaging

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Noninvasive Vascular Diagnostic Studies (93880-93998) Vascular codes for procedures on noncoronary veins and arteries Includes –______ care –________________________ (S&I) –Copy of ______ Reviewed in Chapter 21 of text Patient Supervision and interpretation results

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pulmonary (94002-94799) For ventilation management, therapies, and ________ tests Includes procedure and ___________ of test results –Additional E/M service reported _________ Ventilator management codes –Further divided by _____ of service –Facility is billed ___ day –Home billed by ____ once per month Spirometer. (From Proctor DB, Adams AP: Kinn's The Medical Assistant: An Applied Learning Approach, ed 12, St. Louis, 2014, Saunders.) Exhaling into spirometer. (From Proctor DB, Adams AP: Kinn's The Medical Assistant: An Applied Learning Approach, ed 12, St. Louis, 2014, Saunders.) diagnostic interpretation separately place per time

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Allergy and Clinical Immunology (95004-95199) Divided into three subheadings: –______ Testing (95004-95071) –Ingestion Challenge Testing (95076, 95079) –_______ Immunotherapy (95115-95199) Allergy testing—consists of performance, evaluation, and interpretation of allergens Ingestion Challenge—test for sensitivity to food, drugs, and other substances Immunotherapy—indicated for patients with allergic rhinitis due to seasonal pollinosis caused by trees, grasses, weeds, etc. Allergy Allergen

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Allergy Testing (95004-95071) Sensitivity testing using various types of tests –Example: Percutaneous, ____________, inhalation Tests use numerous substances –Example: Extracts, venoms, biologics, and foods ____ and number of tests based on physician’s judgment Medical record will indicate the –Number of tests –Type of test –Method of testing (Cont’d…) intracutaneous Type

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Ingestion Challenge Testing (95076, 95079) Sensitivity to food, drugs, and other substances 95076 reports initial 120 minutes testing time 95079 reports each additional 60 minutes Services less than 60 minutes, report E/M code

42. Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Allergen Immunotherapy (95115-95199) Codes divided into three types of services: –_______ only –__________ and injection –Provision ______ (substance) only Codes 95115 & 95117 are payable in an office setting (Cont’d…) Injection Prescription antigen

43. Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Allergen Immunotherapy (…Cont’d) Physician service bundled into immunotherapy codes –If separate E/M service provided, report separately with -25

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Neurology and Neuromuscular Procedures (_____-96020) Contains codes to report tests, such as: –Sleep testing –Muscle and range of motion testing –Electroencephalography (EEG) –Neurostimulator procedures –Functional brain mapping Many bundled services Services usually provided in addition to E/M service These are often consultative services (e.g., 99241-99242) 95803

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Central Nervous System (CNS) Assessments/Tests ( ) Used to report: –Psychological tests –Speech/language assessments –Developmental progress assessments –Thinking/reasoning examinations (Cont’d…) 96101-96125

46. Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CNS Assessments/Tests (…Cont’d) Codes based on _______ basis –Except for basic ____________ testing Includes ___________ of results per hour developmental written report

47. Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hydration (96360, 96361) 96360-96361 Infusion: Therapeutic procedure to introduce fluid into body –Example: Fluid into vein for patient rehydration Codes represent infusion service and “_______________ and electrolytes” –Other than pre-packaged, report ________ pre-packaged fluid separately

48. Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hydration, Therapeutic Infusions, and IV Pushes Only ___ initial service per encounter Patient presents for hydration (initial service) –Has drug therapy while being hydrated –Drug therapy is subsequent Report with _______ code –Example: 3 hours hydration with antiemetic by IV push for 15 minutes _____ = hydration, 1 hr _____ × 2 = hydration, hr 2 and 3 _____ = antiemetic IV push one add-on 96360 96361 96375

49. Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration) (96365-96379) Types of Drug Administration Therapeutic Prophylactic Diagnostic Codes divided by administration method Subcutaneous Intramuscular IV Push Intra-arterial Intravenous push –A Push takes __ minutes or less –Over 15 minutes is an _______ –Also report the _________ administered (J code) 15 infusion substance

50. Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chemotherapy Administration (96401-96549) Represents only preparation and administration ____________ –If separate E/M service provided, report E/M code and ___ Chemical can be administered (injected) into –Lesion –Vein –Tissue –Muscle –Artery –Cavity –Nerve (Cont’d…) chemotherapy -25

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chemotherapy Administration (…Cont’d) Intravenously injected chemicals: two methods of delivery of chemical –IV push quickly puts into vein (__ minutes or less) –IV infusion delivers over longer period time (__ minutes or more) Chemotherapy administration codes are covered only when drug being used is an antineoplastic and diagnosis is cancer (Cont’d…) 15

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chemotherapy Administration (…Cont’d) Codes often divided on time of infusion/injection procedure –Example: 96413, Chemotherapy administration, intravenous infusion, __________, single or initial substance/drug When multiple drugs are given by different routes of administration, a separate fee will be paid for each route of administration (Cont’d…) up to 1 hour

53. Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chemotherapy Administration (…Cont’d) Chemical agent (substance) reported _________ Special supplies (e.g., special needles) reported separately using _____ or Level II HCPCS code (Cont’d…) separately 99070

54. Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chemotherapy Administration (…Cont’d) Report any intra-arterial catheter placement (cutdown) with _____ Intra-arterial route has coverage restrictions for Medicare (e.g., coverage is for patients with liver cancer, diagnosis codes 155.0-155.2 and 197.7) and colon cancer that is metastatic to the liver 36640

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Injections with Chemotherapy Report separately any ________ or ________ (for vomiting) –Before or after chemotherapy –Report both the ___________ and J-code analgesic antiemetic administration

56. Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Photodynamic Therapy (96567-96571) Used in addition to bronchoscopy or gastrointestinal codes Injected agent remains in cancerous cells longer than normal cells –After agent dissipates from normal cells, lesion is exposed to ____ light –Agent absorbs light –Photosensitizing agent produces ______ and cancer cells are destroyed laser oxygen

57. Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Special Dermatological Procedures (96900-96999) Usually specialized procedures provided on consultation basis –Separate ___ consultation code then appropriate Treatment of skin conditions: –___________—with ultraviolet light –________________—with light-sensitive chemicals and light rays E/M Actinotherapy Photochemotherapy

58. Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physical Medicine and Rehabilitation (97001-97799) Used by physicians and therapists to report services for variety of treatments –Traction –Electrical stimulation (used to help heal fractures) –Therapeutic exercise Patient training: –___ training –________ activities (Cont’d…) Gait Functional

59. Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physical Medicine and Rehabilitation (…Cont’d) Codes often have ____ components –Example: 97761 reports prosthetic training, per __ minutes Codes divided by type of therapy –Example: physical or occupational ________ are divided by supervised or constant attendance time 15 Modalities

60. Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Active Wound Care Management (97597-97610) Debridement –__________ healthy tissue removed along with necrotic tissue (97602) –Removal of necrotic tissue without anesthesia (97597, 97598) –___________________________ (NPWT) is controlled application of subatmospheric pressure to a wound (97605, 97606) Each code for ongoing care reported on ___ session basis Nonselective Negative pressure wound therapy per (Cont’d…)

61. Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Must document debridement was performed, level of tissue debrided, method of debridement Document the size and character of wound before and after debridement Document a treatment plan and patient education Direct (one-to-one) patient contact Active Wound Care Management (97597-97610) (Cont’d…)

62. Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Osteopathic and Chiropractic Services (98925-98943) Both inpatient and outpatient settings Physician services bundled into codes Codes divided by number of ___________ involved body regions

63. Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Telephone/Online Services (98966-98969) and Special Services, Procedures, and Reports (99000-99091) Non-Face-to-Face Nonphysician Services (98966-98969) report telephone and online E/M services by nonphysicians Handling and conveyance laboratory specimens –99000-_____ Postoperative follow-up visits included in surgical package –_____ Office visits after posted hours or in locations other than office –_____ (24-hour facility) Medicare bundles most of the Special Services procedures (Cont’d…) 99002 99024 99053

64. Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Special Services, Procedures, and Reports (…Cont’d) Supplies and materials (_____) Hospital mandated on-call services (___________) Medication Therapy Management Services (99605-99607) report pharmacist’s services in medication management 99070 99026, 99027

65. Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 30 MEDICINE