Fam Pract Manag. 2001 Nov-Dec;8(10):16.
- Medical decision making requirements
- Signing off on incident-to services
- Immunization codes
- Coding an outpatient hospice visit
- Physician venipuncture
- Awaiting nursing home placement
Medical decision making requirements
To qualify for a given level of medical decision making, does my documentation need to meet all three elements (the number of diagnoses or management options considered, the amount and/or complexity of data to be reviewed and the risk of complications and/or morbidity or mortality) mentioned in the “Documentation Guidelines for Evaluation and Management (E/M) Services,” or is it sufficient to meet two of the three?
Both CPT and the documentation guidelines state that to qualify for a given level of medical decision making (straightforward, low complexity, moderate complexity or high complexity), only two of the three elements must be met.
Signing off on incident-to services
When a nurse practitioner’s services are being billed under Medicare’s “incident-to” provision, does the physician need to review the nurse practitioner’s documentation and sign off on the chart?
No. Nothing in Medicare’s incident-to rules requires the physician to sign off on the nurse practitioner’s documentation as long as the services provided by the nurse practitioner are covered under the incident-to rules. However, given that the incident-to services will be billed in the physician’s name, it might be a good idea for the physician’s own protection to review and sign off on the chart anyway. For more information about Medicare’s incident-to rules, see “The Ins and Outs of ‘Incident-To’ Reimbursement” on page 23 of this issue and read section 2050 of the Medicare Carriers Manual (www.hcfa.gov/pubforms/14_car/3b2049.htm#_1_7).
Should I submit 90471 for immunization administration in addition to an immunization code (e.g., 90737 for Hemophilus influenzae b, Hib, vaccine)?
Yes, 90471 can be submitted in addition to the code for the vaccine itself. Using your example, if you administer Hib, you should submit administration code 90471 and the appropriate CPT code for the Hib vaccine. Note that code 90737, which you referenced, has been deleted; you should use codes 90645-90648 to report the Hib vaccine.
Coding an outpatient hospice visit
Which CPT codes should I use when I see my patients in the hospital hospice ward, which is an outpatient facility?
According to CPT, a patient is considered an outpatient until he or she is admitted as an inpatient to a health care facility. Since there are no CPT codes specific to an outpatient hospice setting, I would recommend using the office or other outpatient services codes (99201-99215).
When a physician performs a femoral venipuncture on a patient but provides no E/M service, what code should we submit?
For venipuncture necessitating a physician’s skill, you should submit CPT code 36410, “Venipuncture, child over age 3 years or adult, necessitating physician’s skill (separate procedure), for diagnostic or therapeutic purposes. Not to be used for routine venipuncture.”
Awaiting nursing home placement
If a hospitalized patient is awaiting nursing home placement, can we still submit hospital inpatient codes for the patient, or should we submit nursing facility services codes instead?
If the patient has been admitted as a hospital inpatient and has not yet been discharged from the hospital while awaiting nursing home placement, you should continue to submit hospital inpatient services codes 99221-99239 as appropriate. According to CPT, the nursing facility services codes are used to report E/M services to patients who are “in nursing facilities (formerly called skilled nursing facilities (SNFs), intermediate care facilities (ICFs) or long term care facilities (LTCFs)).”
Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to FPM.
Conflicts of interest: none reported.
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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 cod ing 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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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
Copyright © 2001 by the American Academy of Family Physicians.
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