Fam Pract Manag. 2001 May;8(5):21.
E/M code + procedure code?
Can we code and be reimbursed for an evaluation and management (E/M) code and a procedure code such as 17000 (for cryosurgery of one lesion) provided during the same encounter only if the patient is a new patient?
An E/M service and an office procedure such as 17000 may both be coded, regardless of the status of the patient. Code 17000 is listed in CPT as a starred (*) procedure. The manual states, “When the starred (*) procedure is carried out at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit is listed with the modifier -25 appended in addition to the starred (*) procedure and its follow-up care.” Note that in order to code the E/M service with the procedure in this situation, the E/M service must be significant and separately identifiable, as indicated by appending the -25 modifier to the appropriate E/M code. Keep in mind that just because you code the services correctly doesn't mean your payer will reimburse you for both.
“Incident to” billing
What codes should we use to bill an “incident to” visit for a midlevel provider (MLP) who sees a Medicare patient as a follow-up to a doctor's visit? We understand the principle of “incident to” services, but we don't know what code to use to bill this to Medicare.
When you bill “incident to,” you're billing as if the doctor provided the service himself or herself, so you should use the office visit code that reflects the levels of history, exam and medical decision making that the MLP provided (assuming the visit took place in the office or other outpatient setting).
Normal newborn care
I have been under the impression that there is a global code for normal newborn care in the hospital that applies regardless of the duration of a healthy infant's stay in the nursery. Recently another physician told me that she bills for both a history and physical on admission day as well as subsequent levels of service for each day in the nursery. Which one of us is correct?
Your colleague is correct. There are separate codes for the history and physical of the normal newborn (99431) and subsequent hospital care provided to such newborns (99433). Thus, it would be accurate to code a history and physical on the day of admission and subsequent newborn hospital care codes for the days following.
Lab results review, revisited
In the January 2001 issue [page 23], I noted that modifier −26, “Professional component,” should be added to the appropriate laboratory CPT code to note the interpretation of lab work done outside the office. Since then, several individuals have contacted me to ask whether this means they can code and be reimbursed for the review of results sent to them by the outside laboratory. The answer is no.
The “professional component” refers to the actual interpretation of the laboratory test and preparation of a separate, distinct, identifiable written report. Most outside laboratories do the professional component as part of the test and provide the physician's office with the report of the results. Review of those results provided by the outside lab does not constitute the “professional component” of the test and cannot be coded separately. Only if a physician were to interpret a test done by an outside lab and produce his or her own written report based on that interpretation would it be appropriate to report the lab code with modifier −26.
The rarity of this in family practice is underscored by the fact that two family physician lab experts we contacted couldn't think of an instance in which modifier -26 would be used by family physicians for lab work. One said, if it were used this way, it would probably “raise red flags and require special justification.”
Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management.
Editor's note:While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.
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