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Outpatient treatment room services

APCs Weekly Monitor, July 8, 2004

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QUESTION: Patients come to a treatment room in our 25-bed hospital for a scheduled visit for intramuscular (IM) or subcutaneous (SQ) injections, infusion therapy, Foley catheter change, etc. The physician does not see the patient; the care is given totally by the nurse. We are picking up the room charge under 99211 under revenue code 761. Is this correct? If this is not correct, what is the correct way to bill these types of outpatient treatment room services?

ANSWER: It is not unusual for a patient to be seen in a hospital setting for scheduled minor procedures. In many of these instances, the physician does not see the patient and the care is provided by either a nurse or ancillary professional (physical therapist, respiratory therapist, etc). There must be proper physician orders for the specific services covering each visit (watch for expired orders with recurring visits). In this scenario, the nurse or ancillary professional is still operating under the supervision of a physician, even if the physician doesn't see the patient directly, and all activities are governed by the hospital bylaws. Medicare's definition of hospital outpatient and encounter at 42 CFR 410.2 applies.

The correct revenue code for these visits depends on where in the hospital the patient is treated. If the patient is treated in a treatment room, use revenue code 761. If the patient is seen in a hospital-based clinic setting, use revenue code 510. Finally, if the patient was seen in a minor surgical room, use revenue code 361. You should verify with your FI and payors that all of these revenue codes are acceptable. In some instances, payors may require an alternative revenue code.

Do not assign a separate E/M code if the service or procedure has a CPT/HCPCS code. Several of your example procedures do have CPT/HCPCS code that should be reported. For example, if the patient recieved an IM or SQ injection, use CPT code 90782, "Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular." If the patient received infusion therapy, use CPT code Q0081, "Infusion therapy, other than chemotherapeutic drugs." If the patient recieved a Foley catheter change, CPT code 51701, 51702, or 51703 could be appropriate depending on the service provided.

If the service provided to the patient does not have a CPT/HCPCS code, assign a visit E/M code (99211-99215) based upon your hospital's criteria for assigning resource utilization to one of the visit codes. An example of this is a patient who presents for a blood pressure check or suture removal.

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