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?