Tools of the Trade
Edition: June 2006 - Vol 14 Number 06
Customers look to their sales reps for product solutions. While it’s difficult for reps to be experts on all the products they sell, they can gain a working knowledge of many, and learn where to go to get questions answered. Repertoire has complied a list of products likely to be sold to your customers in this field. Happy and successful selling!
The ECG is one of the most common non-invasive tests performed in the physician’s office today. An ECG measures the electrical impulses that control contraction and relaxation of the heart. The familiar waveform pattern is a visual record of the amount of voltage activity generated by the heart and the time required for that activity to travel through the heart. Most heart problems can be identified from the abnormalities in heart rate, rhythm and the ECG waveform pattern.
CPT codes for ECG
• 93000: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.
• 93005: tracing only, without interpretation and report.
• 93010: interpretation and report only.
Spirometry is a pulmonary function test that measures how quickly the lungs can move air in and out, as well as how much air the lungs can displace. In a spirometry test, the patient breathes into a tight-fitting mouthpiece connected to the device. Some test measurements require normal, quiet breathing; others call for the patient to take a deep breath and, when told, to exhale the air for as long, hard and fast as possible. The spirometer records the amount or volume of air expelled as well as the rate at which the air is expelled over a specific period.
• 94010: Spirometry complete, includes graphic record total and timed vital capacity, expiratory flow rate measurement(s) with or without maximal voluntary ventilation.
• 94060: Bronchodilation responsiveness; spirometry as in 94010, pre- and post-bronchodilator or exercise.
• 94375: Respiratory flow volume loop.
Holter monitoring, which is also referred to as ambulatory ECG, monitors a patient’s heart during normal activity for 24 to 72 hours. The monitor, a small device worn by the patient, records every heartbeat during that time, increasing the chances that irregular heartbeats, or arrhythmias, can be detected. The monitor is attached to the patient with a multi-lead ECG cable. If the patient experiences any abnormal symptoms, such as chest pain or dizziness, an event button can be pushed that marks the event, so the technician or physician can later view the heart’s activity at that point in time. When the patient returns the monitor, it is disconnected and a report is generated via a computer or printer.
• 93230: Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, micro-processor-based analysis with report, physician review and interpretation.
• 93231: Recording (includes hook up, recording and disconnection).
• 93232: Microprocessor-based analysis with report.
• 93233: Physician review and interpretation.
Stress testing is an evaluation of the patient’s cardiovascular system using an ECG, treadmill and blood pressure unit. The purpose is to screen patients for heart disease and help predict or unmask potential coronary problems. The exercise stress test is used to check for problems that show up only when the heart is working hard, and normally wouldn’t be seen during a routine ECG. During testing and recovery, the office should have a defibrillator and emergency cardiac drugs available.
CPT codes for exercise ECG
• 93015: Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report.
• 93016: Physician supervision only, without interpretation and report.
• 93017: Tracing only, without interpretation and report.
• 93018: Interpretation and report only.
• 93350: Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report (usually reported with CPT 93015/16).
Blood — which carries the oxygen needed by the body’s blood cells — is carried from the heart to the rest of the body through the arteries. Blood pressure is the force of the blood pushing against the artery walls, and is at its highest when the heart beats and pumps blood. This is called systolic pressure. Between beats, when the heart is at rest, blood pressure drops. This is diastolic pressure. Nearly one in three adults in the United States has high blood pressure, according to the American Heart Association. Because there are no symptoms, about one-third of these people are unaware that they have it. Yet, high blood pressure can lead to stroke, heart attacks, heart failure or kidney failure. Low blood pressure can be problematic as well, causing lightheadedness or fainting.
In-office blood pressure monitoring is not reimbursable.
Ambulatory blood pressure monitoring
Ambulatory blood pressure monitoring (ABPM) is a procedure in which a small, automated electronic device, worn by the patient for a period of 24 hours or more, periodically records blood pressure during normal daily activities, including sleep. Clinical studies have indicated that ABPM better predicts target organ damage than blood pressure readings taken in the doctor’s office. The advantages are mostly due to greater quantities of data permitting better assessment of average blood pressure. ABPM helps identify the 15 to 30 percent of “white-coat” hypertensives, or patients with otherwise normal blood pressure levels despite an elevated office reading.
• 93784: ABPM, using a system such as magnetic tape and/or computer disk for 24 hours or longer, including recording, scanning analysis, interpretation, and report.
• 93786: ABPM, using a system such as magnetic tape and/or computer disk for 24 hours or longer; recording only.
• 93788: ABPM, using a system of magnetic tape and/or computer disk, for 24 hours or longer, scanning analysis with report.
• 93790: ABPM, using a system such as magnetic tape and/or computer disk for 24 hours or longer; physician review with interpretation and report.
Ultrasound imaging is based on the same principles used in sonar technology. When a sonographer presses a transducer against the patient’s skin, it directs inaudible, high-frequency sound waves into the body. As the sound echoes from the body’s fluids and tissues, the transducer records the strength and character of the reflected waves. These echoes can be used to determine the distance, size, shape and consistency of an object.
CPT code 76375 may be used to describe 3D ultrasound and 3D echo; this code should be listed in addition to the basic tomographic echo imaging code, such as 93307, 93303 or 93312.
Doppler ultrasound is a form of ultrasound used primarily to evaluate blood flow. Like all ultrasound, it uses a transducer to send high frequency sound waves into the body’s internal structures — primarily, veins and arteries. However, the result is usually not an image or picture, but rather sound, digital read-outs, graphs or even color flow mapping, which tell the doctor information about blood vessels and the way blood is passing through them. It is particularly effective in checking for peripheral arterial disease or chronic venous insufficiency. One of the most common tests performed with the Doppler is the ankle brachial index, or ABI. In this test, the physician uses the Doppler to monitor the blood flow in both arms and both legs. If the systolic pressures are the same, no blockage exists. However, if the ratio of the flow in the ankles to that of the flow in the arms is less than one, then peripheral arterial disease may be present. The smaller the ratio, the more serious the condition.
• 93922: The non-invasive physiologic studies of upper or lower extremity arteries,
single level, bilateral (for example, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement).
Intense pulsed light
New variable IPL systems deliver a sequence of rapid pulses of light energy that can be varied in time, duration and delay time in order to provide the right treatment for different skin conditions and hair removal procedures. In contrast to lasers, which fire one wavelength of light and typically can do one treatment effectively, IPLs deliver several hundred wavelengths of light. Specifically targeting these wavelengths is now possible by varying the way the pulses of light are delivered. That means one machine/many treatments. Variable IPLs are safe, which makes these procedures less intimidating for physicians who do not traditionally treat the skin.
Applications for IPL include hair removal, skin rejuvenation (to remove age spots and fine wrinkles), psoriasis, acne treatment, tattoo removal, benign vascular lesions (such as port-wine stains, hemangiomas, telangiectasia, rosacea, melasma and angiomas), and vein treatment and venous malformations.
IPL treatment is a cash business. No CPT codes.
Fecal occult blood test
Colorectal cancer is the second deadliest cancer in the United States. One of the early warning signs of colorectal cancer is hidden (or occult) blood in the stool, which can be detected by the fecal occult blood test (FOBT). The most common type of test — the guaiac test — relies on a color change when blood is present in a stool sample. Test slides are packaged and sent to a laboratory or doctor’s office for evaluation. A negative test result means no blood was found, while a positive one indicates that blood was found. However, certain foods and medications can interfere with the accuracy of the test results.
The immunochemical fecal occult blood test (FIT) has been available for about 10 years but has been reimbursable by Medicare only since 2003. It is reportedly more specific than traditional FOBTs, as well as easier for patients to use. The FIT works by directly detecting human hemoglobin, making it more specific to lower gastrointestinal bleeding. It does not have the interferences of the traditional guaiac. With both screening tests, a positive reading should be followed with a visible test, such as a colonoscopy or a flexible sigmoidoscopy, to determine the source of the bleeding and possible treatment of the source.
G0107, 82270 and 82272: Guaiac FOBT.
G0328 and 82274QW: Immunochemical FOBT.
Rapid tests: H. pylori, mono, flu, strep, pregnancy
CLIA-waived rapid-test kits give the doctor rapid diagnoses for a variety of indications, including H. pylori, flu, strep and pregnancy.
Helicobacter pylori (H. pylori) (CLIA-waived for whole blood only). H. pylori is a spiral-shaped bacterium found in the gastric mucous layer or adherent to the epithelial lining of the stomach. It is the real culprit behind more than 90 percent of duodenal ulcers and from 50 to 80 percent of gastric ulcers. Before its discovery in 1982, doctors considered the major causes of ulcers to be spicy food, acid, stress and lifestyle; consequently, they treated patients with medications to relieve ulcer-related symptoms, but not the ulcer itself. Today, antibiotic regimens can successfully eradicate H. pylori infection in most patients, with a minimal chance of recurrence.
Infectious mononucleosis, or glandular fever (CLIA-waived for whole blood only). Mono is caused by the Epstein-Barr virus, a member of the herpes virus family, and is found full-blown most commonly in adolescents and young adults. The disease usually isn’t very serious, although the virus remains in the body for life. In fact, most people have been exposed to the Epstein-Barr virus by the time they are 35 years old, and have built antibodies to it. Symptoms include fatigue, loss of appetite and general weakness, especially in adolescents, as well as nausea, jaundice, severe headache, stiffness, chest pain and difficulty breathing. Tests for mononucleosis may not be positive until the patient has been infected for one week after onset. (It peaks at two to four weeks.) Other tests may be needed if the heterophile antibodies are negative, but the doctor still suspects mononucleosis as the cause of the patient’s symptoms.
Influenza, or flu, is a respiratory infection caused by a variety of viruses. The Centers for Disease Control and Prevention estimates that 10 to 20 percent of Americans contract the flu during each flu season. Children are two to three times more likely than adults to get sick with flu, and are more likely to spread it to others. Although most people recover from the illness, more than 114,000 people in the United States are hospitalized each year with flu, and about 36,000 people die of flu or flu-related complications. Influenza infection compromises the mucociliary lining of the respiratory tract and makes individuals susceptible to such bacterial agents as Staphylococcus aureus, Streptococcus pneumonia and Hemophilus influenza. Rapid tests are available that can detect the presence of influenza A and B virus in a patient nasal wash or nasal swab sample within 10 minutes.
Strep throat is caused by Streptococcus pyogenes bacteria, which are spread through airborne droplets when someone with the infection sneezes or coughs. Occasionally, food, water and milk can become contaminated with strep, if someone with streptococcus comes into contact with these substances. Visually examining the patient’s throat can help the doctor diagnose an infection, but there’s no way to tell if it is bacterial (can be treated successfully with antibiotics) or viral (cannot be treated with antibiotics). Consequently, most doctors order a rapid test to check for the presence of streptococcal bacteria. In addition, the doctor may choose to have the patient’s throat swab further tested at a laboratory, especially if the results of the rapid test are negative.
• H. pylori: 86318, 86318QW
• Influenza: 87804, 87804QW
• Strep A: 87880, 8788QW
CLIA-waived lipid panel
Lipids are fat and fat-like substances used by the body as a source of fuel. They include cholesterol, triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL). Lipid disorders are problems that affect the way cholesterol is produced, used, carried in the blood, or disposed of by the body. People with lipid disorders develop very high total cholesterol levels, very low HDL (or “good”) cholesterol levels, and/or high triglyceride levels. Lipid disorders are often inherited. People who have lipid disorders are at risk of developing coronary artery disease, often at an early age. That’s why early detection is important.
• 82465: (cholesterol, serum or whole blood, total).
• 83718: (lipoprotein, direct measurement, high-density cholesterol).
• 84478: (triglycerides).
• 80061: (lipid panel).
CLIA-waived hemoglobin A1c testing
While blood glucose testing monitors day-to-day levels, the hemoglobin A1c test offers a longer-term view — anywhere from two to four months. The test measures the amount of blood glucose attached to one specific place on the hemoglobin molecule inside red blood cells.
As red blood cells travel through the bloodstream, they pick up glucose. The higher the patient’s blood glucose, the more glucose the red blood cells accumulate. Once glucose attaches to hemoglobin, it stays attached for the life of the red cell. HbA1c levels of 5 to 7 percent indicate excellent control of glucose levels, 7 to 9 percent good control, 9 to 10 percent marginal control, and 10 to 14 percent poor control. In the Diabetes Control and Complications Trial (a clinical study conducted from 1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases), the average HbA1c level was 7 to 7.2 percent for people who received intensive treatment. (The average HbA1c in the United States in 2002 was 9.8.)
When the body sustains a wound, the blood clots. Under normal circumstances, this is a healthy response, because clotting helps the body heal itself. But under certain circumstances (e.g., atrial fibrillation, deep vein thrombosis, pulmonary embolism, mechanical heart valves, etc.), this same mechanism can cause an unwanted and life-threatening clot or “thrombus” to form. Patients with these conditions must take oral anticoagulants, which decrease the clotting ability of the blood. These anticoagulants are considered to have a narrow therapeutic index, and the response to a standard dose varies widely both between patients and within patients over time. Changes in patient health, lifestyle or diet can affect changes in the action of anticoagulants. That’s why patients taking them must be tested frequently to make sure they are taking the proper level of anticoagulants. This is the purpose of the prothrombin time test.
Non-waived hematology/hematology analyzer
Hematology is a generic term describing the study of blood and blood-forming tissues. One of the standard tests performed with a hematology analyzer is the complete blood count, or CBC, which helps the physician assess a patient’s general health or to monitor disease. The CBC measures the number of red blood cells (which carry oxygen throughout the body); number of white blood cells (also called leukocytes, which defend the body against infection); total amount of hemoglobin (the protein in red blood cells that carries oxygen in the blood); hematocrit (the proportion of cells and fluids in the blood); and platelet count (an indication of the ability to form blood clots and control bleeding). The CBC and other blood tests can help the physician diagnose a wide variety of conditions, including anemia, blood loss, bone marrow failure, leukemia, clotting problems, congenital heart disease, kidney disease, infectious disease and malnutrition. For this reason, the CBC is one of the most commonly ordered diagnostic tests in the physician office lab.
• 85025: Complete blood count with differential.
Electrosurgery is used for surgical cutting or coagulation (hemostasis) at the surgical site. The technique can be used to remove warts, spider veins or hair in the doctor’s office, as well as for heart, orthopedic or transplant procedures in the operating room. Electrosurgical units deliver high-frequency electrical currents and voltages through an active electrode, causing desiccation (drying out of cells), vaporization or charring of the target tissue. The unit itself is a generator capable of producing a cutting and/or coagulating effect on tissue by the use of alternating current at a high frequency. Voltages and currents vary depending on the desired clinical effect.
(electrosurgery of the skin)
• 11200/11201: Removal of skin tags.
• 11400/11401/11402: Excision, benign lesion (trunk, arms or legs).
• 11420/11421/11422: Excision, benign lesion (scalp, neck, hands, feet, genitalia).
• 11440/11441/11442: Excision, benign lesion (face, ears, eyelids, nose, lips, mucous membrane).
• 11600/11601/11602: Excision, malignant lesion (trunk, arms or legs).
• 17000/17003/17004: Destruction, benign lesion, any method.
Casework is a generic term for medical cabinetry. It is found in a variety of settings, including the physician’s exam or procedure room. Casework systems are modular. That is, they are made up of components (cabinets, countertops, drawers, sinks, etc.) which, when put together to the customer’s specifications, form a total storage solution. The term is usually contrasted with “millwork,” which refers to wood construction (e.g., Formica over particle board or plywood). Because it is modular and pre-fabricated, casework is considered to be equipment, rather than part of the construction or renovation itself.
Power tables feature powered seat-height adjustments and, in some cases, powered backs, to make it easy for patients to get onto and off the tables. This can be particularly important for patients who are obese, elderly or handicapped. Powered-tilt capabilities provide better positioning for patient and doctor during pelvic procedures and difficult exams. Powered-foot options lift the patient’s legs for greater comfort.
Power tables don’t carry a CPT code of their own. Yet, the many exams and procedures they facilitate do carry some of the highest-revenue-generating CPT codes. In a world where doctors’ incomes are being pinched due to cost increases and reimbursement reductions, one way for a physician to generate more income is to start doing procedures in his office. Power tables allow him to do so. After all, the highest revenue generating area for any physician is the procedures room.
Automated external defibrillators
Every two minutes, a person in the United States goes into sudden cardiac arrest. Only 3 to 5 percent of them survive. Each minute that passes without defibrillation may reduce the patient’s chance for survival by up to 10 percent. That’s why it’s important for the victim to receive defibrillation quickly.
An automated external defibrillator (AED) is a portable device that, when applied to a pulseless, non-breathing patient, analyzes the heart’s rhythm and, if necessary, allows a rescuer to deliver an electric shock to a victim of sudden cardiac arrest. This shock, called defibrillation, may halt the rapid and chaotic heart activity of sudden cardiac arrest and help the heart to re-establish an effective rhythm of its own. The AED recognizes two patient rhythms associated with sudden cardiac arrest: rapid ventricular tachycardia and ventricular fibrillation. Some units guide rescuers through all phases of a rescue, including cardiopulmonary resuscitation (CPR).
There are no CPT codes for AEDs. They are used in emergencies should someone collapse and need life-saving intervention.
Last year, the National Cancer Institute estimated that more than 10,000 cases of cervical cancer would be diagnosed in the United States, and more than 3,000 women would die from the disease. Yet with proper screening, cervical cancer is one of the most preventable cancers. Screening for cervical cancer or pre-cancerous lesions begins with a Pap smear. If the Pap smear produces negative or questionable results, OB-GYNs and family physicians follow up with colposcopy. A colposcope is an diagnostic instrument that magnifies and illuminates the cervix by four to 30 times its original size. The physician generally applies vinegar and sometimes an iodine solution to make lesions stand out. If she sees areas of abnormal tissue, she will usually perform a biopsy. Both the colposcopy and biopsy together generally take 20 or 30 minutes to complete.
• 57420: Colposcopy of the entire vagina, with cervix if present.
• 57421: With biopsy(s) of vagina/cervix.
• 57452: Colposcopy of the cervix including upper/adjacent vagina.
• 57454: With biopsy(s) of the cervix and endocervical curettage.
• 57455: With biopsy(s) of the cervix.
• 57456: With endocervical curettage.
Cryosurgery is the use of extreme cold produced by liquid nitrogen (or argon gas) to destroy abnormal tissue. It is used to treat several types of cancer, and some pre-cancerous and non-cancerous conditions as well. In addition to prostate and liver tumors, it can be an effective treatment for retinoblastoma, early-stage skin cancers, pre-cancerous conditions of the cervix and pre-cancerous skin growths.
For external tumors, such as those on the skin, liquid nitrogen is applied to the cancer cells with a cotton swab or spraying device. For internal tumors, liquid nitrogen or argon gas is circulated through a hollow instrument called a cryoprobe, which is placed in contact with the tumor. The doctor uses ultrasound or MRI to guide the cryoprobe and monitor the freezing of the cells, limiting damage to nearby healthy tissue. Sometimes more than one probe is used to deliver the liquid nitrogen to parts of the tumor. The probes may be put into the tumor during surgery or through the skin. After cryosurgery, the frozen tissue thaws and is either naturally absorbed by the body (if an internal tumor), or dissolves and forms a scab (external tumors).
• 55873: Cryosurgical ablation of the prostate when accompanied with ultrasound guidance.
• CPT codes used in cryosurgery for benign lesions are 11200, 11201, 17000, 17003, 17004, 17110, 17111, 46916, 46924, 54050, 54056, 54065, 56501, 56515, 67850.
A pulse oximeter is a noninvasive device that monitors pulse rate and arterial blood oxygen levels — specifically, the percentage of hemoglobin that is saturated with oxygen. (Hemoglobin is the protein in red blood cells that carries oxygen in the blood.) The oxygen saturation level is referred to as SpO2. Pulse oximetry is used as an indication of respiratory function, or how well the body is transporting and using the oxygen being taken into the lungs. This is important in situations where general anesthesia is being administered, since an anesthetic can deprive the body of the oxygen it needs. Pulse oximetry is also used to monitor patients with chronic obstructive pulmonary disease. A sensor is applied to the monitoring site, such as the patient’s finger, toe or forehead. The unit employs light-emitting diodes, which measure the amount of light absorbed; this is related to the degree of oxygenation and hemoglobin in the tissue.
• 94760: Pulse oximetry, single determination.
• 94761: Pulse oximetry, multiple determinations.
• 94762: Continuous overnight monitoring.
Vital signs monitor
Used for years in hospitals, vital signs monitoring is one of the most commonly performed procedures in the doctor’s office. Vital signs include blood pressure, pulse or heart rate, temperature, respiration and oxygen saturation.
Vital signs measurements are typically the first information a physician’s office collects from a patient, because they provide a very basic “dashboard” for a doctor or medical professional to quickly ascertain the patient’s condition. For example, high or low body temperature may indicate that an infection is present, while elevated blood pressure could be a sign of cardiovascular problems.
• 94760: Noninvasive pulse oximetry for oxygen saturation; single determination.
Lighting is measured in terms of color temperature (expressed in Kelvin, or K, units) and footcandles (a measure of light density). A lower color temperature implies warmer (more yellow/red) light, while high color temperature implies a colder (more blue) light. Lighting has many applications in the physician’s office: Ceiling-mounted, wall-mounted and floor-stand units (some on casters for easy positioning) are used for minor surgical procedures and exams. Hand-held and wall-mounted magnifiers and diagnostic lights are used to diagnose injuries to the skin and eye, including corneal scratches, foreign bodies in the eye, blocked tear ducts and fungus infections. X-ray viewers allow for easy viewing of X-ray film. Handles and light covers may be disposable or autoclavable.