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The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Coding for multiple injections, medication, fluoroscopy and orthography present challenges for coders working on orthopedic claims. In most cases, clear physician documentation can avoid confusion with coding claims.
"In the case where a claim is denied or reviewed on audit, the more specific the documentation made by the physician, the better the practice or physician is going to look in appealing the denial," says Bill Gilbert, vice president of marketing at AdvantEdge Healthcare Solutions (AHS). Physicians should dictate whether the injection took place on the right or left side of the body, or whether it was bilateral.
However, the coder should also be familiar with the payor regulations. Here are three key clarifications for coders processing injection claims.
1. Bundling injection codes. Corey Stavinski, CPC, of AHS, and Peggy Bothwell, LPN, CPC, coding manager at AHS, say coders should bundle injections according to Medicare and CCI guidelines. In most cases, Medicare and the payors who follow CCI guidelines expect injections to be bundled. As always, clear documentation and an explanation of what was done and why helps the coder identify those exceptions where the injections can be unbundled. One example is a patient that receives injections to both shoulders in two separate procedures. Some commercial payors do not follow the CCI guidelines. For these payors, additional injections may be able to be unbundled.
For trigger point or muscle injections, coders use CPT 20552 for an injection to one or two muscles, and CPT 20553 for three or more muscle injections, says Deborah McEachern, CPC, of McEachern Medical Coding & Consulting. If there are multiple procedures done, the coder should capture the dominate procedure code and then use the -59 modifier for the lesser procedures. Physicians should clearly state the number of injections performed in order for the coders to accurately bundle or use the appropriate modifiers if there are two separate procedures.
2. Billing for medication. Coders should become familiar with the contracts between the payor and facility because some practices bill for medications or supply trays, while others consider these expenses part of the global package, say Ms. Stavinski and Ms. Bothwell. If the center bills for the medication, the coder must identify the correct HCPCS code and specify the amount used. In the instance of a single-use medication, the physician should document the amount left over because wastage can be coded and billed.
Medicare packages medication and supplies; however, there are certain drugs that Medicare will pay for separately, so coders should double check whether unfamiliar drugs can be billed separately.
3. Fluoroscopy and arthrography. Physicians use fluoroscopy for needle localization and guidance to make sure they are injecting in the correct location. Arthrography can also be used for guidance but it has diagnostic purposes as well. Some payors, such as Medicare, will not reimburse for fluoroscopy or arthrography in some joints. Ms. Stavinski and Ms. Bothwell say that clear physician documentation is necessary to code for the instances when physicians are able to receive reimbursement. In the operation report, physicians must include a description of the patient's anatomy, structures, where the needle was placed, the spreading of the dye, what type of dye was used and the findings within the joint area. The findings can be included in the operation report or in a separate report; it is helpful to the coder if the findings are at least in a separate paragraph in the operation report.
Additionally, coders need to know whether the equipment is owned and maintained at the facility. If the physician is using equipment owned and maintained by a hospital, he or she cannot bill for the use of that equipment.
Learn more about AdvantEdge Healthcare Solutions.
Learn more about McEachern Medical Coding & Consulting.
Read other coverage on orthopedic coding:
- 3 Critical Knee Arthroscopy Coding Pitfalls Impacting an ASC's Bottom Line
- 5 Tips for Increased Accuracy in Orthopedic Coding
- Improving Reimbursement for Spine Surgeons: 6 Tips for Communicating With Coders
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Coding for multiple injections, medication, fluoroscopy and orthography present challenges for coders working on orthopedic claims. In most cases, clear physician documentation can avoid confusion with coding claims.
"In the case where a claim is denied or reviewed on audit, the more specific the documentation made by the physician, the better the practice or physician is going to look in appealing the denial," says Bill Gilbert, vice president of marketing at AdvantEdge Healthcare Solutions (AHS). Physicians should dictate whether the injection took place on the right or left side of the body, or whether it was bilateral.
However, the coder should also be familiar with the payor regulations. Here are three key clarifications for coders processing injection claims.
1. Bundling injection codes. Corey Stavinski, CPC, of AHS, and Peggy Bothwell, LPN, CPC, coding manager at AHS, say coders should bundle injections according to Medicare and CCI guidelines. In most cases, Medicare and the payors who follow CCI guidelines expect injections to be bundled. As always, clear documentation and an explanation of what was done and why helps the coder identify those exceptions where the injections can be unbundled. One example is a patient that receives injections to both shoulders in two separate procedures. Some commercial payors do not follow the CCI guidelines. For these payors, additional injections may be able to be unbundled.
For trigger point or muscle injections, coders use CPT 20552 for an injection to one or two muscles, and CPT 20553 for three or more muscle injections, says Deborah McEachern, CPC, of McEachern Medical Coding & Consulting. If there are multiple procedures done, the coder should capture the dominate procedure code and then use the -59 modifier for the lesser procedures. Physicians should clearly state the number of injections performed in order for the coders to accurately bundle or use the appropriate modifiers if there are two separate procedures.
2. Billing for medication. Coders should become familiar with the contracts between the payor and facility because some practices bill for medications or supply trays, while others consider these expenses part of the global package, say Ms. Stavinski and Ms. Bothwell. If the center bills for the medication, the coder must identify the correct HCPCS code and specify the amount used. In the instance of a single-use medication, the physician should document the amount left over because wastage can be coded and billed.
Medicare packages medication and supplies; however, there are certain drugs that Medicare will pay for separately, so coders should double check whether unfamiliar drugs can be billed separately.
3. Fluoroscopy and arthrography. Physicians use fluoroscopy for needle localization and guidance to make sure they are injecting in the correct location. Arthrography can also be used for guidance but it has diagnostic purposes as well. Some payors, such as Medicare, will not reimburse for fluoroscopy or arthrography in some joints. Ms. Stavinski and Ms. Bothwell say that clear physician documentation is necessary to code for the instances when physicians are able to receive reimbursement. In the operation report, physicians must include a description of the patient's anatomy, structures, where the needle was placed, the spreading of the dye, what type of dye was used and the findings within the joint area. The findings can be included in the operation report or in a separate report; it is helpful to the coder if the findings are at least in a separate paragraph in the operation report.
Additionally, coders need to know whether the equipment is owned and maintained at the facility. If the physician is using equipment owned and maintained by a hospital, he or she cannot bill for the use of that equipment.
Learn more about AdvantEdge Healthcare Solutions.
Learn more about McEachern Medical Coding & Consulting.
Read other coverage on orthopedic coding:
- 3 Critical Knee Arthroscopy Coding Pitfalls Impacting an ASC's Bottom Line
- 5 Tips for Increased Accuracy in Orthopedic Coding
- Improving Reimbursement for Spine Surgeons: 6 Tips for Communicating With Coders