Health Information Management

Codes subject to OCE Edit 15 named

APCs Insider, May 28, 2003

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Codes subject to OCE Edit 15 named

CMS put Edit 15 (service unit out of range for procedure) back in play on April 1, 2003, but did not identify which OPPS codes would be affected by the edit. The following six codes are currently subject to the edit:

  • C2616 - Brachytx seeds, Yttrium-90
  • G0256 - Prostate brachy with palladium
  • G0261 - Prostate brachy with iodine
  • G0273 - Pre-treatment planning for non-Hodgkins disease
  • 76090 - Mammogram, one breast
  • 76091 - Mammogram, both breasts
CME currently has 60 different edits. Only two, edit 7 for procedure and age conflict and edit 51 for multiple observations overlapping time, are not activated. For more information on the OCE Edit 15, see PM A-03-019.

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TODAY'S TOPIC: How to code education and evaluation of self-administering therapy

Question: Do we use code 94664 only when a patient will be self-administering his or her therapy? Is a specific physician's order required for the patient to be taught? What is included in the initial therapy? Does it include the routine education or is it specific to those patients who will be using the therapy at home? Should 94640 ever be used for the initial treatment?

Answer: 94664 includes the demonstration and/or evaluation of patient use of an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing device. This service may be provided in various hospital outpatient departments or in the ER.

94664 can only be reported one time per day. It includes the education by the respiratory therapist prior to the patient self-administering the treatment. This service should either be ordered by the physician, or a committee-approved patient protocol.

94640 is used to report the actual treatment typically administered by an RT or RN. This code can be reported more than once on the same day if modifier -76 is appended.

However, according the the National Correct Coding Initiative, 94664 must be entered alone when demonstrating the use of the respiratory device to the patient.

If a treatment is given on the same, by the same personnel in the same department as the demonstration/evaluation of the patient use of the device, 94664 becomes a component of the more comprehensive procedure 94640.

When the demonstration/evaluation is performed in a different department, by different personnel, it may qualify for modifier -59.

When using these treatments in the ER, 94640 carries a status indicator of S so it is not subject to multiple procedure discounting. If this is the only procedure performed during the visit, modifier -25 should be appended to the E/M level code to ensure reimbursement for this procedure.

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PAY PER VIEW: The bane of bunion coding: Too many codes to choose from

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Coding and Compliance Feature Article of the Month: Interventional procedures cause coding confusion

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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