CODING Q&A Readers’ Coding Inquiries ■ DAVID STERN, MD, CPC Q . I had a patient who presented with a hydroflu- oric acid burn to the fingertips—right hand worse than left. First I had to acquire some calcium gluconate gel. I applied this to all of his fingertips for 30 minutes, and it helped a little. I proceeded with a modified bier block with calcium gluconate. I applied a BP cuff tourniquet to his arm, and then injected Ca gluconate intra- venously. The blood pressure cuff remained fully in- flated for 20 minutes. He remained on an ECG monitor during this procedure. This reduced his swelling and de- creased his pain some, but not completely. I sent him home with his hands in latex gloves hold- ing Ca gluconate paste over all his fingertips, and I will see him again tomorrow. How would you code this visit? - Question submitted by Marshall Plotka, MD, Phoenix Emergency Care This is a great coding conundrum, and a classic case in which correct coding can maximize revenue. Here are some ideas for coding this visit: Ca gluconate paste application and dressing: One cannot use the code for treatment of a first-degree burn (16000), as this code is specifically limited to situations in which “no more than local treatment is needed.” (Note: If you do per- form repeat dressings, you could code future visits with 16000.) The appropriate code in this case, however, is 17999 (unlisted procedure, skin, mucous membrane and subcuta- neous tissue). When billing an “unlisted procedure,” make sure that you include documentation of the procedure, time spent, and any difficulties or complications. You could price this code similarly to your fee for 16000. A. David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.prac- ticevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m IV drug push: Code with 90774 (therapeutic, pro- phylactic, or diagnostic in- jection—specify substance or drug); intravenous push, single or initial substance/ drug). Ca gluconate IV: Code with J0610 (calcium glu- conate, up to 10 ml); code once for each 10 ml or frac- tion of 10 ml. Bier block: Code with 64999 (unlisted procedure, nerve). CPT 2007 has been revised to state, “When re- gional intravenous administration of local anesthetic agent or other medication in the upper or lower extremity is used as the anesthetic for a surgical procedure, report the appro- priate anesthesia code. To report a Bier block for pain man- agement, use 64999.” Again, when billing an “unlisted procedure,” make sure to include documentation of the procedure, time spent, and any difficulties or complications. Note: Fees across the coun- try seem to range from $180 to $230. E/M: Document and code the appropriate evaluation and management (E/M) code (99201-99215). If more than half of your time involves counseling the patient about the treat- ment and prognosis, you may consider time as the deter- mining factor in determining the appropriate E/M code. This is particularly appropriate in the setting of worker compensation claims, as you will need to investigate and doc- ument the circumstances of the injury, determine if the pa- tient is predisposed to complications due to factors such as diabetes or smoking, evaluate the viability of the extremity, discuss your findings and recommendations with the work- place, and spend a significant amount of time reviewing the prognosis and treatment of the injury with the patient. Don’t forget to add modifier 25 to the E/M code, as you have performed a procedure along with the E/M code. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | J u l y/A u g u s t 2 0 0 7 31