1. Chapter 8
Medicine

2. Diagnostic, therapeutic, and miscellaneous procedures and services
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

3. 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

4. Injections and Infusions: Immune Globulins
Immune globulins provide protection against certain diseases
Injections
Intramuscular
Subcutaneous
Intravenous

5. Injections and Infusions: Vaccination and Toxoid Administration
Immunity: body produces antibodies in response to antigen exposure
Antigens: Bacteria, viruses, fungi
Route of administration
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

6. Injections and Infusions: Hydration
Hydration: administration of prepackaged fluid and electrolytes (not drugs)
Codes are based on time
96360 – one hour
96360 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 96360
96361 – add-on for each additional hour

7. 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

8. 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

9. 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)

10. 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

11. 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)

12. Coding in the inpatient setting for ESRD and non-ESRD patients
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

13. Gastroesophageal reflux disease (GERD)
Gastroenterology
Gastroesophageal reflux disease (GERD)
Acid in esophagus, changes pH
Tests for pH
Manometric studies for motility
Capsule endoscopy: “camera pill”

14. Ophthalmology Ophthalmology: the study of the eye
92002– 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

15. 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

16. 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

17. Cardiovascular Services: Echocardiography
Ultrasound of the heart chambers, valves, great vessels
2D or Doppler
Complete or limited studies
Transthoracic
Transesophageal

18. Cardiovascular Services: Cardiac Catheterization
Component coding
One catheter placement code
All applicable injection procedure codes
Imaging supervision and interpretation codes

19. Cardiovascular Services: Cardiac Catheterization
Procedures included in cardiac catheterization codes and not coded separately
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

20. 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

21. 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

22. 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

23. 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

24. Allergy Services Immunotherapy is treatment
Codes provided for testing by:
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

25. 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:
Airflow
Respiratory effort
Gas exchange
Limb muscle activity
Extended EEG
Penile tumescence
Gastroesophageal reflux
Continuous blood pressure monitoring

26. Electroencephalography (EEG)
Neurology: EEG and EMG
Electroencephalography (EEG)
Records electrical activity in the brain
Recording time determines code
Used to determine brain death
Electromyography (EMG)
Records electrical activity in muscle(s)
1–4 extremities
Larynx
Hemidiaphragm

27. Chemotherapy Administration
Services included in chemotherapy codes:
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

28. 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)

29. 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:
Application of hot or cold packs
Mechanical traction
Electrical stimulation
Vasopneumatic devices
Paraffin baths
Whirlpool
Diathermy
Infrared
Ultraviolet

30. 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

31. Physical Medicine and Rehabilitation
Training for activities of daily living (ADL) are coded in 15-minute increments.
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

32. Physical Medicine and Rehabilitation: Acupuncture and Chiropractic
Acupuncture: needles are inserted under the skin
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

33. 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