1. Privileges and Billing for Ultrasound Guided Injections Maurice Sholas, MD, PhD Sholas Medical Consulting, LLC AAPM&R Annual Meeting 2014

2. Objectives  Review credentialing for practitioners using Ultrasound Guidance for injections.  Review ICD-10 classification and billing/coding compliance  Documentation templates to allow billing optimization I have no relevant conflicts of interest to disclose.

3. The Challenge of an Important but “Dry” Topic

4. Credentialing  Committee discretion/perogative is important  Clarify that practitioners are NOT seeking diagnostic ultrasound privileges (radiology-like interpretation of structures and pathology)  Can see it as an extension of existing privileges to inject Botulinum toxins or Phenol/Alcohol  Some see it as a separate skill that requires separate privileging

5. For Separate Credentialing  Need documentation of training  As a part of Residency/Fellowship  As part of a mini-course or hands-on symposium  Need proctorship of 2-5 cases depending on local preference  Clarification of access to U/S equipment is important as well.  Does the Practice own the equipment  Will Practice access equipment owned in Radiology or OR

6. Billing for the Procedure Include code for the procedure Include code for component used to localize the procedure Include professional service modifier if needed Rules different if ultrasound technician used.

7. Ultrasound Guided Botox Injection of the Leg Old ICD-9 System  Botox Injection of non- head/neck: 64614 64646  Injection peripheral nerve: 04.2 (unspecified 04.8)  Ultrasound guidance for needle placement: 76942  Professional Component identifies the physician component of a technical act: Modifier 26 New ICD-10 System  Botox Injection:  Injection peripheral nerve: 3E0T3TZ  Ultrasound guidance for needle placement:  Professional Component:

8. Similar Addition to Base Charge Code  Ultrasound guidance for needle placement: 76942  Professional Component identifies the physician component of a technical act: Modifier 26  ITB Pump Refill (6236X)  Phenol Nerve Block (64640)  Salivary Gland Botulinum Toxin Injection (64613)

9. What is ICD-10 CM?  International Statistical Classification of Diseases and Related Health Problems, 10 th revision, clinical modification  Based on the World Health Organization system that classifies and codes all symptoms, diagnoses and procedures with an alphanumeric designation  The evolution of the ICD-9 system that took the 13,000 codes and created 68,000 alphanumeric ones and increased the number of organizational categories

10. Old Versus the New ICD-9 CM  3-5 digit code  14,000 total codes  Procedure Codes for ICD-9 are 3-4 numbers  ICD 9 procedure codes number only 4,000 ICD-10 CM  3-7 digit code  68,000 total codes  Procedure Codes (ICD-10 PCS) are 7 characters  ICD 10 PCS contains 87,000 codes

11. Angioplasty Code Comparison  ICD-9 CM  Only one code: 39.50  Cannot specify any additional details via this code  ICD-10 PCS  854 codes  Specifies the body part, approach and device used  Ex: 047K04Z is dilation of right femoral artery with drug-eluting intraluminal device, via open approach

14. The Upside - Celebration  ICD-9 is outdated in that it does not allow as precise and identification of the patient condition and experience  ICD-9 is more than 30 years old and does not reflect changes in disease process, treatment knowledge, or medical technology.  There is a limit to how the ICD-9 codes can be expanded to accommodate new diseases, treatments and sub-classifications  ICD-10 provides more specific detail  ICD-10 can be expanded in the future  Change would bring the US into compliance with the rest of the industrialized world WRT classification.

15. The Challenges  The increased number of codes, the change in the number of characters per code, and increased code specificity, this transition will require significant planning, training, software/system upgrades/replacements, as well as other necessary investments.  There is a divergence in inpatient versus outpatient systems. ICD-10 PCS will be used for inpatient procedures, but CPT and HCPCS codes will be used for outpatient and office procedures.  Small practices can expect to spend anywhere between $56,639 to $226,105. The new estimates factor in the costs associated with purchasing new software to accommodate the new codes. (Nachimson Associates via AMA Report, 2/12/2014)  At least transient increase in insurance denials as all sort out the “right” codes to be used for each case in question.

16. When is ICD-10 CM Coming?  Initially October 1, 2014.  On April 1, 2014, the President signed into law the Protecting Access to Medicare Act of 2014. (SB 951/HR 4302)  While the primary focus of the law is to provide a temporary patch to the Sustainable Growth Rate (SGR) for physician payment, Section 212 establishes a delay for the implementation of ICD-10.  The language states that the Secretary of Health and Human Services (HHS) may not adopt the ICD-10 code sets prior to October 1, 2015.

17. Resources  http://www.medicaid.nv.gov/Downloads/provider/ICD- 10_Overview_2013-0524.pdf http://www.medicaid.nv.gov/Downloads/provider/ICD- 10_Overview_2013-0524.pdf

18. Resources

20. Documentation Phrases  “The flexor digitorum profundus was identified using ultrasound guidance and the appropriate fascicle verified using electrical stimulation. 10 units of botulinum toxin A were injected using…” Allows billing for Botox, Ultrasound and Electrical Stim.  “The parotid salivary gland was identified using surface anatomy and palpation and needle placement confirmed by ultrasound imaging.” Allows Botox and Ultrasound billing for injection.

21. Questions?