If you use ICD-9 procedure codes for outpatients claims being sent for payment, you shouldn't be

Friday,
September 19, 2003
Vol. 4, No. 37

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Keith Siddel,
MBA, PhD (c),
president, CEO
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Cheryl D'Amato,
RHIT, CCS,
director, health information management
HSS, Inc.

Julie Downey,
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University Colorado Hospital

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Julia R. Palmer
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president, Health Information Management Division
HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System

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If you use ICD-9 procedure codes for outpatients: Stop

Some hospitals may use the ICD-9 procedure codes internally to create a map to CPT codes. Hospitals can use the procedure codes internally, but not on claims that are being sent for payment.

Outpatient facility coders should be aware that after October 16, they can no longer use ICD-9 procedure codes on outpatient claims.

"Although your facility may have set up a system to accept ICD-9 procedure codes on both an inpatient and outpatient basis, it is now mandated by law that ICD-9 is applicable only to inpatient claims, and CPT-4 is the designated code set for outpatient," says Candace Shaeffer, RN, MBA, RHIA, vice president of Coding/Quality at LYNX Medical Systems in Bellevue, WA.

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Question: If a patient comes into a clinic for a dressing change which entails wet to dry dressings and a re-dress, but is not seen by a physician, can we only charge the low-level visit or can it be a 99212 based on the complexity of the dressing change?

Answer: First, there is no requirement that the patient see a physician during an outpatient visit. Second, coding depends on the type of dressing change. There are codes for dressing of burns (16000-16030) and non-selective debridement for other types of wounds (97602), but generally the charge for changing dressings is included in the E/M charge.

Payment for CPT code 97602 is recognized under the OPPS as a packaged service, i.e., the service is not separately paid under OPPS; however, the cost of the service is packaged into whatever other service is provided on that date. It is common for 97602 to be performed at the time of another physical therapy service in which case payment for 97602 is packaged into payment for the other physical therapy service.

If a service coded under 97602 is performed at the time of a clinic or emergency visit, the E/M service must be documented in accordance with the hospital's documentation guidelines for clinic and emergency visits. If the only service provided to a beneficiary is 97602, the hospital may bill outpatient visit code 99211. Payment for 97602 will be packaged into the payment for 99211.

If a hospital provides and bills for 97601 or 97602 and a clinic or emergency department visit, the clinic or emergency visit must be separately identifiable and documented in accordance with the hospital's guidelines for clinic and emergency visits.

When there is no separate code for the dressing change, we suggest that you rely upon your facilities resource level charge for assigning E/M levels for this type of visit. As in the emergency room, CMS has instructed hospitals to create a charge structure based upon resource consumption for the outpatient clinic areas.

Differences in coding guidelines among CMS, local carriers, and other organizations create frustration and confusion when a coder or biller tries to determine why a Correct Coding Initiative (CCI) edit is occurring.

Read more HERE. The cost is $10. Briefings on APCs subscribers have free access via their online subscriptions.

Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.

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