Physiatrists should be extremely specific when reporting arthritis ICD-9 codes, because many insurers cover procedures for rheumatoid arthritis (714.0) but deny the same services provided to osteoarthritis (715.xx-716.xx) patients and vice-versa.
According to the American Academy of PM&R (AAPMR), more than 40 million Americans have arthritis, most of whom have osteoarthritis. Physiatrists not only treat the actual arthritis pain but also offer injections, therapy and exercise instruction to treat joint injuries and help slow degeneration.
Although most insurers cover certain procedures, such as joint injections (20600-20610) for both osteoarthritis and rheumatoid arthritis (RA), they have approved some drugs only for treating RA. Consequently, if you assign an osteoarthritis ICD-9 code to these claims even accidentally the payer will immediately deny it.
Use Remicade for RA Only
Remicade (J1745) is FDA-approved for treating RA, but the FDA has not approved its use for osteoarthritis patients. "Infusing Remicade takes well over an hour," says Danielle Ware, office manager at the Tomkins Joint Center, a six-physician multispecialty practice in Newark, N.J. Tomkins reports 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the first hour of infusion and +90781 (... each additional hour, up to 8 hours [list separately in addition to code for primary procedure]) for each hour thereafter.
Because 90780 applies only when the physician or someone under his or her direct supervision performs the infusion, do not report this code if the physician is off-site. "If the nurse practitioner is with the patient during the infusion, we bill her services incident-to using the physician's number," Ware says.
She notes that the physician always evaluates patients thoroughly before scheduling them for Remicade infusions. "When the patient first comes to our practice, we report an E/M code ( CPT 99201 - 99205 ) for their visit with the physician, and we start the Remicade treatments the next time they come in."
During the Remicade treatments, Ware bills only for the drug and the infusion and does not report an E/M code "unless a patient came in for a regularly scheduled infusion and had another problem requiring physician contact." In that case, Ware would append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
Carriers Don't Always Pay
Most PM&R practices routinely administer bursa injections (20600-20610) to arthritis patients. Although most insurers cover these injections for both osteoarthritis and RA, some carriers' coverage limitations differ based on the patient's condition.
Because arthritis is a chronic condition, physiatrists often inject multiple sites during the same visit, but carriers such as Utah Medicare limit patients to [...]