Knowledge Base Category -

Question:

What is the significance of coding the National Institutes of Health Stroke Scale Scores (NIHSS) that were implemented in 2017?

Answer

The NIHSS is a neurological exam that is scored on all acute stroke patients. The provider or clinician will calculate and document the score. The coder is to assign R29.7—based on the score or scores.

CMS has been gathering claims data on strokes from July 1, 2018 - June 30, 2021 which will be publically reported in FY 2022. For FY 2023 the data will start affecting hospital reimbursement as part of the 30-Day Stroke Mortality Measure. Hospitals should report the first NIHSS, which is typically documented after arrival to the hospital along with the appropriate stroke code. You may report additional NIHSS codes and use the POA indicator No for those additional codes.

In a recent Wednesday@One article (link) and related Infographic, RTMD’s claims data revealed only 40.1% of the claims included an NIHSS code. The reason the reporting of the NIHSS codes is so low may be due to the wording of the coding guideline. The guideline states, codes R29.7—may be used in conjunction with the stroke codes, so many hospitals are opting not to code them.

The main point of this article is to make sure you always report a NIHSS code with an acute stroke code and that they appear on the claim. Omitting the R29.7- code will adversely impact your hospital’s future reimbursement.

Question:

During cataract extraction, the physician sometimes injects an antibiotic into a part of the eye anatomy. Can we code the injection procedure(s) in addition to the cataract extraction CPT code?

Answer

No, do not code the eye injection in addition to the CPT code for the cataract extraction. This applies to the injection of an antibiotic as well as steroids and non-steroidal anti-inflammatory drugs Specific examples of injections not separately reportable with the cataract extraction code include: anterior chamber, intravitreal, retrobulbar, Tenon’s capsule, and subconjunctival.

Question:

A patient came to the ER and a CT of the abdomen and pelvis without contrast (CPT code 74176) was performed. While the patient was still in the ER, the patient went back to CT a second time and a CT abdomen and pelvis with contrast was performed, in other words – two separate scans. Can CPT codes 74176 and 74177 be billed together on the same date of service, and if so, is a modifier needed? Or do we have to report only one CPT code 74178 (CT abdomen and pelvis with and without contrast)?

Answer

If the payer uses Medicare’s National Correct Coding Initiative (NCCI) edits, you can bill CPT codes 74176 and 74177 on the same date of service. A modifier is needed to indicate the scans were separate and distinct from each other, i.e., two separate scans. Depending on the payer, use modifier 59 or XU.

When a patient has only one visit to the CT department for CT abdomen and pelvis with and without contrast as a single study, you must bill CPT code 74178. In this scenario, it would be inappropriate to bill CPT codes 74176 and 74177 with a modifier as this would constitute unbundling.

Question:

You mentioned in last week’s Wednesday@One outpatient FAQ (link) that Palmetto GBA considers the drug ‘Imitrex’ to be a self-administered drug. Does that apply only to the Imitrex brand, or does it also apply to the other Imitrex formulations / brands?

Answer

All formulations of Imitrex would be considered a self-administered drug under Palmetto. Take a look at Palmetto’s self-administered drug list link and in the Imitrex section, you will see other names of Imitrex listed, which include:

• Imitrex Statdose Pen
• Zembrace Sym touch
• Alsuma
• Sumavel DosePro

Although not listed, this should also include the drug Tosymra, which is another brand name for Imitrex.

Question:

We have another question about self-administered drugs based on prior outpatient FAQs for Lovenox and insulin. (Click for the Lovenox article and for the insulin article.) Is the drug ‘Imitrex’ a self-administered drug for Medicare? Usually, we see this given to patients in the ER who present with migraine type headaches.

Answer

For Palmetto, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, Imitrex is a self-administered drug when given by subcutaneous route. For Medicare, you would NEVER report a subcutaneous injection (CPT code 96372) for Imitrex. If you are under the jurisdiction of a different MAC, check their respective self-administered drug list as the drugs can vary from one MAC to the next.

Here is a link to Palmetto’s self admin drug list. It is a very handy reference to see which injectable drugs are considered self-administered drugs at least – for hospitals under the jurisdiction of Palmetto GBA.

Local Coverage Article for Self-Administered Drug Exclusion List

Question:

As a follow-up to last week’s question about Lovenox, (link) we have the same question regarding insulin: We have NOT been charging for insulin administration given in any form (ex. IM, Infusion), but should we?

Answer

Palmetto, GBA considers Insulin to be a self-administered drug when given by subcutaneous route. For Medicare, you would NEVER report a subcutaneous injection for insulin (CPT code 96372). Palmetto says if you give insulin by a different route, it is appropriate to report the administration CPT code, such as IM or IV.

Cahaba, GBA the prior Medicare Administrative Contractor (MAC) for Jurisdiction J, had told Provider that insulin is a self-administered drug regardless of the route. The Palmetto policy is not as strict as Cahaba’s.

Again, here is a link to Palmetto’s self-administered drug list, which includes discussion about drugs on the list given by other than subcutaneous route.
Local Coverage Article for Self-Administered Drug Exclusion List

Remember, insulin is sometimes documented using other names, and it is easy to miss these drugs if you are not familiar with some of the brand names. If you need a reminder, review the Wednesday@One article at the link below from September 2018 which lists some of the more common insulin names and types.

Do You Know When to Code Z79.4?
https://www.mmplusinc.com/kb-articles/do-you-know-when-to-code-z79-4

Question:

Is Lovenox in the outpatient setting a self-administered drug for Medicare? Can we charge for the administration?

Answer

For Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, Lovenox is NOT a self-administered drug, so you can charge for the subcutaneous / intramuscular injection, CPT code 96372. If you are under the jurisdiction of a different MAC, check their self-administered drug list as the drugs can vary from one MAC to the next.

Here is a link to Palmetto’s self-administered drug list. It lists all of the injectable drugs they consider to be self-administered: Local Coverage Article for Self-Administered Drug Exclusion List (cms.gov)