DAVID STERN, MD (Practice Velocity)
Q. What codes should we use in place of the discontinued 90701 (tetanus vaccines, diphtheria, tetanus toxoids, and whole cell pertussis vaccine [DTP], for intramuscular use) and 90718 (tetanus and diphtheria toxoids [Td] absorbed when administered to individuals 7 years or older, for intramuscular use) that were discontinued effective July 1, 2012?

A. You should use 90714 (Tetanus and diphtheria toxoids [Td] absorbed, preservative free, for use in individuals 7 years or older, for intramuscular use) because only preservative-free Td is available for administration.
DTP is a cellular vaccine that caused many untowed reactions. It is no longer used in the USA, and the Tdap vaccine is used instead. Use 90715 {Tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], for use in individuals 7 years or older, for intramuscular use).

Q. When giving a TB skin test, can we charge for a subcutaneous injection?
A. Use CPT 86580 (Skin test; tuberculosis, intradermal) for purified protein derivative (PPD) testing in the office. This test is not a vaccine; rather, it is a screening test for the presence of an immune response, indicating the presence of tuberculosis. I addition, code 86580 includes intradermal injection of the substance.

The AMA Resource Based Relative Based Relative Value System (RBRVS) does not include the work for reading the test. Therefore, you can also code 99211 for the nurse reading. However, per incidence-to-regulations, the physician must be in the office at the time of the reading in order to code the 99211.

If the test is positive, you can code for the additional services rendered during the visit. Typically, the physician will perform a face-to-face encounter with the patient for further evaluation and management (reviewing the diagnosis, physical exam, risk, possibility of a false-positive test, treatment options, etc.) You would code the E/M appropriately (99212 – 99214). You would also want to code for any additional testing (such as a chest x-ray).

The appropriate ICD-9 code is V74.1, Special screening examination for bacterial and spirochetal diseases; Pulmonary tuberculosis.

Q. How would I code and bill for adult and child Epi-Pens? Is HCPCS code J3490 the correct code, using the number of injectable pens as 1 unit?
A. You can bill for the injection administration using CPT 96372, “therapeutic, prophylactic, or diagnostic injection … subcutaneous or intramuscular” along with the medication itself. Some payors will accept HCPCS code J0171, “Adrenalin, epinephrine” while others may prefer HCPCS code J3490, “Unclassified drugs.” You will want to check with the payor to see which is required. Remember that if you bill J3490, you will want to include the drug name and dosage in Box 19 of the CMS 1500 form.

The code for the medicine is the same for a child and for an adult.

Q. When coding for intravenous (IV) therapies, CPT says to document the time. Is it sufficient to document the length of time of the IV as opposed to the start and stop times?
A. There is no specific requirement for documenting start and stop times, but hydration therapy cannot be reported if it is performed as a concurrent infusion. For example, during hydration therapy, an IV push of a medicine was given in the same IV site. Because the push was given concurrent with the hydration, you cannot count the duration of the push towards the total time of the hydration.

In the event of an audit, you would want those times documented in order to show that services were billed appropriately. Therefore, I would strongly recommend that start and stop times of each IV therapy service provided be documented.

Q. I am opening a walk-in urgent care clinic as part of my primary care practice and am encountering resistance with reimbursement. A major payor has stated it will not reimburse code S9088 and that they will only reimburse for the E/M codes. Who recognizes S9088, 99050, 99051 codes and how much is the reimbursement for all three codes?

A. You are correct in noticing that reimbursement for certain codes can make a significant difference to the financial health of your urgent care center. We have executed 500+ urgent care contracts. It is important for centers to negotiate these rates up front, as payors are usually quite resistant to these discussions once the contract is signed.

In states that are new to private urgent care centers, we have to do a lot of education of payors in order to get them up to speed about reasonable terms for urgent care centers.

I would like to share the rates that you should expect from each payor, but unfortunately the government forbids sharing or rates as a violation of antitrust statutes.

Note: CPT codes, descriptions, and other data only are copyright 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the
American Medical Association (AMA).

Disclaimer: JUCM and the authors provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.

Tetanus Code Change, Coding Injections and Infusions, Facility and After Hours Codes

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine