Coding for Rectal Strep and Injury Exposure Visits, Billing for Slit Lamp Exams, and a Follow-up on Splinting

DAVID STERN, MD (Practice Velocity)

Q. What is the correct ICD-9 code for rectal strep?

Question submitted by Cindy Reisbeck, Littleton, CO

A. There are several possible codes. The specific ICD-9 code would depend on a more specific diagnosis. For streptococcal infections in the rectal or perirectal area, there are several possible correct codes, as streptococcal species can cause multiple different types of localized conditions.

For cellulitis, the correct code would be 566; for erysipelas, the correct code is 035; for impetigo the correct code would be 684; and for necrotizing fasciitis the correct code would be 728.86 (see Table 1).

Q. How do you code out for injury exposure visits (mostly for needlestick injuries) and for hepatitis B immune globulin (HBIg) and subsequent visits for the three-month and six-month labs?

Question submitted by Carlene Cox, Genesis FirstCare, Zanesville, OH

A. You would code all these visits with the appropriate E/M code. Follow-up visits that do not involve the doctor may be coded with 99211, if your staff delivers and documents an appropriate level of care.

If more than 50% of provider face-to-face time involves counseling, then E/M codes may be coded by time.
For many of these visits, you might use the ICD-9 code V15.85 (Personal history of contact with and (suspected) exposure to potentially hazardous body fluids). Prior to 2010, there was no appropriate code for patients that had only a suspected exposure to body fluids, but the definition of this code has been updated this year, to include even a suspected exposure.

For the HBIg, you should use the injectable supply code 90371 (Hepatitis B immune globulin (HBIg), human, intramuscular use) and the code for intramuscular injection 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).
Table 2 reviews the updated (in 2009) CPT codes for injections.

Q. An urgent care physician whose claims I process attended a seminar in Michigan where you lectured. The physician believes that you said that there is a code for a slit lamp exam when there is no foreign body removed.

I have investigated this situation and the consistent answer I am getting is that if there is not a foreign body removal, then the slit lamp exam is not separately billable form the E/M code.

What is your understanding of this subject?
Question submitted by Theresa Krynski, Accurate Billing Service, Warren, MI
A. You are correct. I am not sure what he understood, but it might relate to one of the following two facts:

1. When the doctor performs an eye exam, you may consider using the ophthalmology E/M codes (92002, 92004, 92012, 92014). Some payors may deny payment with the reasoning that only an ophthalmologist may use these codes. Neither CMS nor the AMA, however, restricts these codes to services provided by ophthalmologists. With good documentation of the level of exam and a clear understanding of the code definitions, you are likely to win an appeal. Per your contract with any specific payor, however, the payor may retain the right to restrict codes to specific specialties.
2. In addition, if you code using 99201-99215, you get credit for additional elements in the CMS 1997 E/M guidelines (eye algorithm) when you use a slit lamp.
3. This question is directly related to a question that was printed in the July/August 2010 issue of JUCM. In regard to coding and billing for splints, you stated that it is appropriate to bill Q4022 [or other appropriate supply code] for splint supplies. I would like to know if it is appropriate for us to bill that code, as we also use molded fiberglass splints. Thus, we split bill our claims. I have been told that Q4022 is not appropriate for facility billing [UB-04]. However, is it appropriate to bill it on the professional side [CMS-1500]?

Question submitted by Marie Garcia, Casa Grande Regional Medical Center Urgent Care, Casa Grande, AZ

4. If your hospital has chosen to split bill the urgent care visits, then the supplies are not billed on the CMS-1500, as the CMS-1500 is used (in the case of split billing) only for professional services (not supplies). As a general rule, you should code all applicable HCPCS codes on the UB-04. However, per the Medicare Claims Processing Manual (http://www.cms.gov/manual/downlaods/clm104c04.pdf):

“When medical and surgical supplies (other than prosthetic and orthotic devices as described in the Medicare Claims Processing Manual, Chapter 20, 10.1) described by HCPCS codes with status indicators other than ‘H’ or ‘N’ are provided incident to a HCPCS codes with status indicators other than ‘H’ or ‘N’ are provided incident to a physician’s service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.”

Q4022 is a code with a Status Indicator of “B” (codes not recognized under OPPS 00 Outpatient Prospective Payment System), so you do not report this code (or other splint supply Q codes) on the UB-04.

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine