It Not Just What You Do, It Is What You Write: Billing and
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Transcript It Not Just What You Do, It Is What You Write: Billing and
Privileges and Billing
for Ultrasound Guided
Injections
Maurice Sholas, MD, PhD
Sholas Medical Consulting, LLC
AAPM&R Annual Meeting 2014
Objectives
Review credentialing for practitioners using Ultrasound
Guidance for injections.
Review ICD-10 classification and billing/coding
compliance
Documentation templates to allow billing optimization
I have no relevant conflicts of interest to disclose.
The Challenge of an
Important but “Dry” Topic
Credentialing
Committee discretion/perogative is important
Clarify that practitioners are NOT seeking
diagnostic ultrasound privileges (radiology-like
interpretation of structures and pathology)
Can see it as an extension of existing privileges to inject
Botulinum toxins or Phenol/Alcohol
Some see it as a separate skill that requires separate
privileging
For Separate Credentialing
Need documentation of training
As a part of Residency/Fellowship
As part of a mini-course or hands-on symposium
Need proctorship of 2-5 cases depending on local
preference
Clarification of access to U/S equipment is important as
well.
Does the Practice own the equipment
Will Practice access equipment owned in Radiology or OR
Billing for the
Procedure
• Include code for the procedure
• Include code for component
used to localize the procedure
• Include professional service
modifier if needed
• Rules different if ultrasound
technician used.
Ultrasound Guided Botox
Injection of the Leg
Old ICD-9 System
New ICD-10 System
Botox Injection of nonhead/neck: 64614 64646
Botox Injection:
Injection peripheral nerve:
04.2 (unspecified 04.8)
Ultrasound guidance for
needle placement: 76942
Professional Component
identifies the physician
component of a technical act:
Modifier 26
Injection peripheral nerve:
3E0T3TZ
Ultrasound guidance for
needle placement:
Professional Component:
Similar Addition to Base
Charge Code
Ultrasound guidance for
needle placement: 76942
Professional Component
identifies the physician
component of a technical act:
Modifier 26
ITB Pump Refill (6236X)
Phenol Nerve Block
(64640)
Salivary Gland Botulinum
Toxin Injection (64613)
What is ICD-10 CM?
International Statistical Classification of Diseases
and Related Health Problems, 10th revision, clinical
modification
Based on the World Health Organization system that
classifies and codes all symptoms, diagnoses and
procedures with an alphanumeric designation
The evolution of the ICD-9 system that took the 13,000
codes and created 68,000 alphanumeric ones and
increased the number of organizational categories
Old Versus the New
ICD-9 CM
ICD-10 CM
3-5 digit code
3-7 digit code
14,000 total codes
68,000 total codes
Procedure Codes for ICD-9
are 3-4 numbers
Procedure Codes (ICD-10
PCS) are 7 characters
ICD 9 procedure codes
number only 4,000
ICD 10 PCS contains 87,000
codes
Angioplasty Code
Comparison
ICD-9 CM
ICD-10 PCS
Only one code: 39.50
854 codes
Cannot specify any additional
details via this code
Specifies the body part,
approach and device used
Ex: 047K04Z is dilation of
right femoral artery with
drug-eluting intraluminal
device, via open approach
The Upside - Celebration
ICD-9 is outdated in that it does not allow as precise and
identification of the patient condition and experience
ICD-9 is more than 30 years old and does not reflect changes in
disease process, treatment knowledge, or medical technology.
There is a limit to how the ICD-9 codes can be expanded to
accommodate new diseases, treatments and sub-classifications
ICD-10 provides more specific detail
ICD-10 can be expanded in the future
Change would bring the US into compliance with the rest of
the industrialized world WRT classification.
The Challenges
The increased number of codes, the change in the number of
characters per code, and increased code specificity, this
transition will require significant planning, training,
software/system upgrades/replacements, as well as other
necessary investments.
There is a divergence in inpatient versus outpatient systems.
ICD-10 PCS will be used for inpatient procedures, but CPT
and HCPCS codes will be used for outpatient and office
procedures.
Small practices can expect to spend anywhere between $56,639
to $226,105. The new estimates factor in the costs associated
with purchasing new software to accommodate the new codes.
(Nachimson Associates via AMA Report, 2/12/2014)
At least transient increase in insurance denials as all sort
out the “right” codes to be used for each case in question.
When is ICD-10 CM
Coming?
Initially October 1, 2014.
On April 1, 2014, the President signed into law the Protecting
Access to Medicare Act of 2014. (SB 951/HR 4302)
While the primary focus of the law is to provide a temporary
patch to the Sustainable Growth Rate (SGR) for physician
payment, Section 212 establishes a delay for the implementation
of ICD-10.
The language states that the Secretary of Health and Human
Services (HHS) may not adopt the ICD-10 code sets prior
to October 1, 2015.
Resources
http://www.medicaid.nv.gov/Downloads/provider/ICD10_Overview_2013-0524.pdf
Resources
Resources
Documentation Phrases
“The flexor digitorum profundus was identified using
ultrasound guidance and the appropriate fascicle verified
using electrical stimulation. 10 units of botulinum toxin
A were injected using…” Allows billing for Botox,
Ultrasound and Electrical Stim.
“The parotid salivary gland was identified using surface
anatomy and palpation and needle placement confirmed
by ultrasound imaging.” Allows Botox and Ultrasound
billing for injection.
Questions?