Coding and Documentation
Answers to Your Questions
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Fam Pract Manag. 2000 Jan;7(1):17.
- Workers' compensation visits
- Same-day office visit and hospital admission
- Sharing a global maternity care code
- Blood gases interpretation
- Hospital discharge and nursing home admission
- Initial inpatient care not provided by the admitting physician
Workers' compensation visits
What code should I use for a workers' compensation examination?
CPT codes 99455 and 99456 are both designated to cover work-related or medical disability exams. The first covers an exam provided by the treating physician, and the second covers an exam provided by someone other than the treating physician. According to CPT, both codes should be used to report “evaluations performed to establish baseline information,” when “no active management of the problem(s) is undertaken during the encounter.” If other evaluation and management (E/M) services or procedures are performed for the patient on the same date, you should also report the appropriate E/M or procedure code. Attaching a -25 modifier might help ensure that both services are reimbursed.
Same-day office visit and hospital admission
In “Coding and Documentation” [“Two Physicians, One Admission,” September 1999], you stated that one physician may bill an E/M code for an office visit provided to a patient on the same day another physician admits that patient to the hospital. Our Medicare carrier informs us that this would not be reimbursable if both physicians are with the same group practice, unless one or both provided critical care. Can you clarify this for us?
I believe your Medicare carrier is correct. In a group practice, all the claims usually are submitted under one group Medicare provider number, making your example analogous to the exception my original answer described, in which one physician provided both the office visit and the hospital admission but could only be reimbursed for the admission. My original answer assumed that the two physicians were otherwise unaffiliated.
Sharing a global maternity care code
How should we bill prenatal services for patients seen by a family physician when an obstetrician performs the delivery? Since the patient is seen in two different departments, by two different physicians, can't we code our services separately? Some payers want us to bill a global fee.
From a CPT perspective, it is inappropriate to code a global maternity care code if not all parts of the global service were provided. In the situation you described, you should code an antepartum care code (e.g., 59426), and the obstetrician should code a delivery only code (e.g., 59409 or 59410). If the insurer requires that a global code be used, another way to identify that you provided the prenatal services is to use the global code (e.g., 59400) with a -56 modifier, “Preoperative Management Only.” Because this approach would not be appropriate according to CPT, you should check with your payer before trying it. For more information, you may want to consult the AAFP's discussion paper on "Coding for Intrapartum Care and Other Obstetrical Services."
Blood gases interpretation
How should I code for blood gases, interpretation only?
The CPT codes for blood gases (82800–82810) include both the technical and professional components. If you are providing the interpretation and report only, you will want to add modifier -26, “Professional Component,” to the appropriate lab code.
Hospital discharge and nursing home admission
A nursing home patient is being discharged from a hospital and readmitted to the nursing home. The physician attending in the hospital is also the attending at the nursing home and has been following the patient. Can the physician submit a hospital discharge code (99238–99239) as well as a nursing facility admission code (99303) on the same day?
Yes. According to CPT, “Hospital discharge ... performed on the same date of nursing facility admission or readmission may be reported separately.”
Initial inpatient care not provided by the admitting physician
When a family physician initially sees a hospitalized patient who was admitted by another physician, should the family physician use an initial or subsequent hospital care code?
The initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting [emphasis added] physician,” according to CPT. For initial inpatient encounters provided by a physician other than the admitting physician, you should use either the initial inpatient consultation codes (99251–99255) or subsequent hospital care codes (99231–99233), as appropriate.
Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.
Copyright © 2000 by the American Academy of Family Physicians.
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