Find out which you can report separately: a tunneled or a non-tunneled line.

Question: What code should we bill when we remove a central venous pressure (CVP) line and insert a Hickman catheter at a different site?

New York Subscriber

Answer: You can’t determine the proper code based on type of catheter (such as CVP line or Hickman).

Selecting the proper code depends on the patient’s age, whether the surgeon places the catheter centrally or peripherally, where the catheter tip is at the end of placement, and whether the catheter is tunneled or non-tunneled.

Surgeons typically place Hickman catheters as central lines, and they usually place them centrally, although they can be tunneled or non-tunneled. For an adult patient, that makes the most likely codes for your scenario either 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) or 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older).

Caution: Before using these codes, you should verify that there was no port or pump attached to the catheter. Also check to be sure that the catheter was actually placed into the subclavian, innominate, or iliac veins, the inferior or superior vena cava, or the right atrium through a central vein (such as jugular or femoral). If any of these facts don’t match your case, you should select a code other than 36556 or 36558.

Tip: Carefully read the directions preceding 36555 before you choose the code. Don’t guess if the procedure note doesn’t specify everything that you need to know. Hickmans are versatile catheters and you can’t be sure what the surgeon did unless it’s in the note.

Separate removal: You can bill separately for the removal of a tunneled central line (such as 36589, Removal of tunneled central venous catheter, without subcutaneous port or pump), but not a non-tunneled line.

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You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently?

New Hampshire Subscriber

Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if your insurance company requires it — which might be why you received a denial.

Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as …

… 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]). You might need to append modifier 25 if vaccinations are given, depending on the payer’s guidelines.

Sick visit: If the child visits because of another problem and receives immunizations during the visit, report the vaccines with the appropriate office visit code from 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient …).

Then report the vaccine codes: 90634 (Hepatitis A vaccine, pediatric/adolescent doage-3 dose schedule, for intramuscular use), 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated -D-TaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use), and 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use).

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Accounting for depth is a tricky task when coding closure.

Practices interested in ethically boosting their bottom line and getting $80 or more for the same closure repair need to walk the line that separates simple from intermediate.

What Makes a Repair “Simple”?

A wound closure is a simple repair if the procedure:

• is simple;
• is a single-layer closure involving the epidermis, dermis, or subcutaneous tissues; and
• does not involve deeper structures.

Code these closures with 12001-12021, confirms Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa. And remember that simple repair includes “local anesthesia, and chemical or electrocauterization of wounds not closed,” she continues.

Example: The ED physician examines a 22-year-old patient’s scalp wound …

Utilizing prolene sutures the physician closes a 2.3 cm single-layer wound. On the claim, you’d report 12001 (Simple repair of wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for this encounter.

Simple, Intermediate: Does It Really Matter?

If you’re interested in more money for the same service, knowing the difference between simple and intermediate repairs is vital.

Example: Let’s say the ED physician closes a 2.9 cm laceration on a patient’s forehead. You report 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the service; encounter notes justify an intermediate repair because the physician needed to perform layered closure of the wound, however, so you should have opted for 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).

Payout: The wrong code here will cost you about $90. The 12013 code pays about $111 (3.08 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666). You’ll corral about $191 for 12052, however (5.08 RVUs multiplied by 36.0666).

OK, How Do Simple and Intermediate Differ?

Simple repairs involve only the epidermis, dermis, and subcutaneous tissues; intermediate repairs also involve the superficial fascia (non-muscle).

Code these closures with 12031-12057, says Santiago.

Good tip: When looking at the encounter notes, if coders can tell that the physician is “in the fascia, then it’s not simple but intermediate,” says Santiago. There are two main types of intermediate repair scenarios. In the first, the notes typically indicate that the physician performed a layered closure of a deeper area on the patient’s wound.

“Depth is best reported by anatomical level instead of measured distance,” says Jeffery Linzer, MD, FAAP, FACEP, associate medical director for compliance for the Emergency Pediatric Group at Children’s Healthcare of Atlanta at Egleston.

Type 1 example: The ED physician performs a level three E/M service for a patient with an open cut on his forearm. Notes indicate that the injury “penetrated the dermis, through to the fascia. No infection present.” Using a layered repair the physician closes the deeper tissues with vicryl and the skin with nylon sutures as part of 2.6 cm repair; she then dresses the wound.

This is an intermediate repair due to wound depth. On the claim, report the following:

• 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) for the repair
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and repair were separate services.

What About Single-Layer Intermediate Fixes? Find your answer at www.supercoder.com.

© ED Coding Alert. Download your 2 FREE sample issues here.

Uncover other reimbursement hot spots you could be missing. Join Carol Edelberg, CPC, CCS-P, CHC for “Top ED Procedures Most Coders Miss.”

Related articles:

1. Coding Education: Simple, Intermediate or Complex Closure?Correctly distinguish closure levels every time with this advice from...
2. Simple Laceration Repair Code or E/M Code? Answer Could Cost Hundreds Not recognizing a laceration repair that’s included in an...
3. Multi-Laceration Repair Coding Case StudiesDo you know when to code repairs that occur in...

Accounting for depth is a tricky task when coding closure.

Practices interested in ethically boosting their bottom line and getting $80 or more for the same closure repair need to walk the line that separates simple from intermediate.

What Makes a Repair “Simple”?

A wound closure is a simple repair if the procedure:

• is simple;
• is a single-layer closure involving the epidermis, dermis, or subcutaneous tissues; and
• does not involve deeper structures.

Code these closures with 12001-12021, confirms Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa. And remember that simple repair includes “local anesthesia, and chemical or electrocauterization of wounds not closed,” she continues.

Example: The ED physician examines a 22-year-old patient’s scalp wound …

Utilizing prolene sutures the physician closes a 2.3 cm single-layer wound. On the claim, you’d report 12001 (Simple repair of wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for this encounter.

Simple, Intermediate: Does It Really Matter?

If you’re interested in more money for the same service, knowing the difference between simple and intermediate repairs is vital.

Example: Let’s say the ED physician closes a 2.9 cm laceration on a patient’s forehead. You report 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the service; encounter notes justify an intermediate repair because the physician needed to perform layered closure of the wound, however, so you should have opted for 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).

Payout: The wrong code here will cost you about $90. The 12013 code pays about $111 (3.08 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666). You’ll corral about $191 for 12052, however (5.08 RVUs multiplied by 36.0666).

OK, How Do Simple and Intermediate Differ?

Simple repairs involve only the epidermis, dermis, and subcutaneous tissues; intermediate repairs also involve the superficial fascia (non-muscle).

Code these closures with 12031-12057, says Santiago.

Good tip: When looking at the encounter notes, if coders can tell that the physician is “in the fascia, then it’s not simple but intermediate,” says Santiago. There are two main types of intermediate repair scenarios. In the first, the notes typically indicate that the physician performed a layered closure of a deeper area on the patient’s wound.

“Depth is best reported by anatomical level instead of measured distance,” says Jeffery Linzer, MD, FAAP, FACEP, associate medical director for compliance for the Emergency Pediatric Group at Children’s Healthcare of Atlanta at Egleston.

Type 1 example: The ED physician performs a level three E/M service for a patient with an open cut on his forearm. Notes indicate that the injury “penetrated the dermis, through to the fascia. No infection present.” Using a layered repair the physician closes the deeper tissues with vicryl and the skin with nylon sutures as part of 2.6 cm repair; she then dresses the wound.

This is an intermediate repair due to wound depth. On the claim, report the following:

• 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) for the repair
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and repair were separate services.

What About Single-Layer Intermediate Fixes? Find your answer at www.supercoder.com.

© ED Coding Alert. Download your 2 FREE sample issues here.

Uncover other reimbursement hot spots you could be missing. Join Carol Edelberg, CPC, CCS-P, CHC for “Top ED Procedures Most Coders Miss.”

Related articles:

1. Coding Education: Simple, Intermediate or Complex Closure?Correctly distinguish closure levels every time with this advice from...
2. Simple Laceration Repair Code or E/M Code? Answer Could Cost Hundreds Not recognizing a laceration repair that’s included in an...
3. Multi-Laceration Repair Coding Case StudiesDo you know when to code repairs that occur in...