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Reader Questions: Report 2 Codes for Embolization and Aortogram

Use 37204 for Embolization

Question: The interventional radiology chart states a diagnosis of "infrarenal abdominal aortic aneurysm." The physician performed an abdominal aortogram with embolization of the right hypogastric artery. Which CPT codes should I report?


Virginia Subscriber

Answer: You should describe the hypogastric artery embolization with 37204 (Transcatheter occlusion or embolization, percutaneous, any method, non-central nervous system, non-head or neck) and 75894 (Transcatheter therapy, embolization, any method, radiological supervision and interpretation), and the aortogram with 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation). And if the physician performed the hypogastric arteriogram prior to the embolization, you should also report 75736 (Angiography, pelvic, selective or supraselective, radiological supervision and interpretation).

Include Heparin Flush in Supply Charge

Question: Can our facility charge for supplies? For example, the nurse performed a heparin flush and administered IV fluids (D5W - 5 percent dextrose, lactated ringers, 0.9 percent NaCl).


Utah Subscriber

Answer: Yes, you can charge for non-routine supplies - including intravenous (IV) fluids - but there is no separate code to describe "heparin flush." However, the tubing and needle used to administer the fluids would be considered "routine" and, therefore, not separately billable. In certain states, Medicaid will reimburse your facility separately for some fluids. You will also receive payment from insurers that reimburse a percentage of the charges you bill. Medicare, however, will package such items with the related procedure or service in the outpatient setting.

Remember: When billing for fluids, use revenue code 258.

Account for Injection Drugs

Question: I'm having trouble choosing the correct CPT code for nerve blocks performed with a mixture of a steroid and anesthetic - for example, Aristocort and ropivacaine. The physician says the code is 64450, but my encoder leads me to add 64999. Am I missing something, or should I report 64450 - which only describes the anesthetic - without 64999?


Delaware Subscriber

Answer: While you would probably get unquestioned reimbursement if you only reported 64450 - whereas you will have to explain why you chose the unlisted-procedure code for the steroid - you shouldn't solely report a code that disregards the steroid use, because both components of the injection are working together.

You would be correct in reporting 64450 (Injection, anesthetic agent; other peripheral nerve or branch) for the anesthetic and 64999 (Unlisted procedure, nervous system) for the steroid injection. Use of the unlisted-procedure code will allow the payer to review the documentation and determine whether additional reimbursement is warranted for the steroid.

Destroy 1, Destroy All

Question: Is it acceptable to retain remittance advices in the form of scanned documents stored on CD (as the only form of retention)? We would destroy the paper copies.


Massachusetts Subscriber


Answer: Legally, reproductions of these documents have the same properties as the originals, so you won't gain anything by destroying only the original documents. Warning: If you haven't destroyed all copies, even the digital or electronic ones, opposing counsel can subpoena the records in a suit.

The only solid reason to convert the documents into non-paper forms is to preserve the information more stably, which seems may be the case. Otherwise, if you're going to destroy the originals, you should destroy the information in all other formats as well.

Question: I understand that when we see an established patient in an outpatient setting (place of service 22) and perform an E/M and procedure, we need to document all three key components to bill the E/M with modifier -25. But if the E/M is above and beyond the procedure, is it true that we only need to have two of the three components?


Colorado Subscriber

Answer: Yes - to bill an evaluation and management code with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) for an established patient, you only need to have two of the three components (history, physical examination, or medical decision making) documented.

Keep in mind: You shouldn't bill an E/M code with a planned procedure unless it represents a truly separately identifiable issue.

For example, if an established patient comes in for a planned procedure, such as a bone marrow biopsy, and then the physician performs an E/M service for a separately identifiable problem, such as a rash, you can bill the E/M code with modifier -25 with only a history and physical exam.

But if the physician sees a patient for the first time (and you're reporting a consult or new patient code) and decides at that time to do an unplanned procedure - such as a bone marrow aspiration - you'll need the history, exam, and medical decision-making to bill the E/M and procedure with modifier -25.

Remember to stick to your facility's individual requirements for E/M codes. According to CMS, "As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes," the agency "will assume that [the facility] is in compliance with these reporting requirements as they relate to the clinic/emergency department visit code reported on the bill."

Resubmit Without Denied Code

Question: Can we remove a charge from a hospital bill in order to earn reimbursement for the rest of the bill? The insurer denied the entire claim but told us that if we took the charge out, it would pay the rest of the bill. The code in question is 92018 for an ophthalmology exam. Is this compliant?


Wisconsin Subscriber

 
Answer: The first thing you need to do is make sure 92018 (Examination under anesthesia) isn't the only code that's holding up the claim. For example, was 92018 a component of another procedure performed during the
same session? If not, find out whether 92018 simply is not covered by this insurer. If so, you should remove the code or reflect it as noncovered and refile the claim. If the code is for a procedure that isn't covered by the intermediary, resubmitting the claim is just like resubmitting a claim with an invalid ICD-9 code - the insurer denies it, and you send it in again correctly.

Many insurers do pay for 92018, including Medicare, so check to make sure. For instance, Champus/Tricare  reimburses for this code at an average of $133.10.

Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.