Q. At the UCA Fall Urgent Care conference, you welcomed all questions, so here goes: Can you please let me know if it is appropriate to charge for Ortho-Glass and fiberglass splints in the urgent care setting? In some cases, the splints are applied by a tech under the direct supervision of the physician. In other cases, can the charge for the application of the splint be coded in addition to the Q code?
Question submitted by Joan Stephanofsky
A. Yes, cast and splint application codes (in addition to the Q codes for supplies) may be used when appropriate in a physician office, and emergency department, an urgent care center, or any other clinical location. You may use the application codes if the physician applies the splint or if staff that are directly supervised by the physician apply the splint.
We have trouble getting reimbursed for E/M codes on the same claim as procedure codes, even if we use modifier -25 on the E/M code. I have even received a denial of the E/M code when billed with a G0168.
Question submitted by Lina, Keith, & Company 6
- When calculating reimbursement for the code G0168 (Wound closure utilizing tissue adhesive(s) only), CMS included relative value units (RVUs) for an E/M, the cost of the 2-cyanoacrylate, and the work to apply the tissue glue. Thus, it is not appropriate to add an E/M code to G0168. HCPCS code G0168, however, should be used only for CMS payors.
For other payors, you should review the CPT definition for wound closure: “CPT repair codes (12001-13160) are used to designate wound closure using sutures, staples, or tissue adhesives (i.e., 2-cyanoacrylate), either singly or in combination with adhesive strips.”
Thus, for payors that are not governed by CMS, you should use the standard CPT code for wound closure, along with an E/M with modifier -25, as long as a separately identifiable E/M is documented in the chart.
Q. We own our x-ray equipment and read all of our x-rays. A radiologist also reads each x-ray. I do use modifier -25 on my EM and modifiers -TC & -26 plus body location on my x-ray. I was told that I should not add modifier -TC not modifier -26 to the bill. Which is correct?
Question submitted by Kimberly, Express Pediatrics
A. You should use modifier -26 only when you are billing for the professional component alone.
You should use modifier -TC only when you are billing for the technical component alone.
When you are billing for both the professional component and the technical component on the same claim, you should bill the CPT code without modifier -26 and without modifier -TC. Using a modifier to indicate anatomic location (i.e., -R for right and -L for left) is appropriate.
I assume that the radiologist works for you as an employee or independent contractor. If so, you may bill the global radiology code (x-ray code without any modifier) for the x-ray. The code includes the professional component and the technical component. You do not need to add modifier -25 to the E/M code if the only procedure performed during the visit is the x-ray.
Q. If I bill an E/M with 96360 (Intravenous Infusion, hydration; Initial, 31 minutes to 1 hour) and J7030 (Infusion, normal saline solution, 1000 cc), do I need modifier -59 on the CPT code 96360?
A. In general, modifier -59 is reserved for when you are coding for services that would otherwise be considered bundled together. You should not use modifier -59 if neither code could be considered as bundled into the other code.
For example, modifier -59 should be used when a patient has two separate lacerations on two different fingers – one laceration involves the tendon and requires a tendon repair (CPT code: 26418, Extensor tendon repair, dorsum of finger, single, primary or secondary, without free graft, each tendon) and the other laceration involves a simple repair (CPT code: 12001, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less).
The code for tendon repair assumes and includes a simple skin closure over top of the repaired tendon and the other laceration, so one would not generally add a code for a simple laceration repair to a tendon repair.
In this specific example, however, the simple laceration repair is on a different finger, so it is clearly distinct from the tendon laceration repair. Thus, the simple laceration repair should be coded as a simple skin closure (12001), and modifier -59 should be added to CPT cod 12001.
In addition, when the lacerations are on different fingers, the coder should also use the modifiers particular to specific fingers (modifiers -F0 to -F9).
In this specific question that you ask, however, the E/M code and the IV code are obviously distinct procedures that are never bundled together in either code. Thus, it would not be a standard coding procedure to use modifier -59.
In addition, when the lacerations are on different fingers, the order should also use the modifiers particular to specific fingers (modifiers -F0 to -F9).
In the specific question that you ask, however, the E/M code and the IV code are obviously distinct procedures that are never bundled together in either code. Thus, it would not be a standard coding procedure to use modifier -59.
In addition, the CPT code for IV hydration (96360) includes the fluids administered to the patient. Thus, it is not appropriate to add J7030 to CPT code 96360.
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for education purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
DAVID STERN, MD (Practice Velocity)
