Fam Pract Manag. 2002 Jan;9(1):18.
Preventive care & the E/M guidelines
Our coding department is wedded to the 1997 version of Medicare’s E/M documentation guidelines and thinks we need to count everything. When we do a comprehensive, age-appropriate history and review of systems for the preventive medicine services codes, is there a fixed number of systems we have to check and questions we have to ask?
No, it is generally understood that the documentation guidelines are not applicable to the preventive medicine services codes for the following reasons:
According to CPT, “the extent and focus of the [preventive medicine] services will largely depend on the age of the patient,” which means a preventive medicine “comprehensive” history and exam for an infant will differ from that of a 65-year old. Thus, the preventive medicine services codes are defined based on patient age, rather than the level of history, exam and medical decision making applied to other E/M codes.
CPT also states that “the ‘comprehensive’ nature of the preventive medicine services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the ‘comprehensive’ examination required in [E/M] codes 99201-99350.” This is a revision for CPT 2002 that attempts to clarify the “comprehensive” nature of these services [see “CPT: What’s New for 2002?” on page 16 for more information]. Here, CPT is drawing a clear distinction between the terminology used in the preventive medicine services codes and other E/M codes.
The 1997 documentation guidelines state that “this publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominantly of counseling or coordination of care. The three key components – history, examination and medical decision making – appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services and home services.” Note that there is no mention of preventive medicine services in this list.
Review of blood-gas analysis
I was recently denied payment for a blood-gas analysis that I billed for using code 82803 and modifier -26, “professional component,” because the insurance company said the analysis is part of the subsequent hospital care code, 99233. Is that right?
Yes. According to CPT, “All levels of subsequent hospital care include reviewing the medical record and reviewing the results of diagnostic studies 85 since the last assessment by the physician.” There is no professional component assigned to 82803. The rationale is that any “interpretation” done is not an analysis of data resulting from the test but a review of the results of the test and a determination of how best to integrate the results of the test into the patient’s care plan. This review of data and coordination of care is an element of the E/M service.
Draining a hematoma
What are the CPT and ICD-9 codes for the drainage of a subungual hematoma of the fourth finger?
The appropriate CPT code is 11740, “Evacuation of subungual hematoma.” The corresponding ICD-9 code is 923.3, “Contusion of upper limb, Finger,” which includes hematomas of the fingernail.
THANKS TO OUR REVIEW PANEL
These questions and answers were reviewed by the FPM Coding & Documentation Review Panel, which includes:
Robert H. Bosl, MD, FAAFP, Starbuck Clinic, Starbuck, Minn.; Thomas A. Felger, MD, ABFP, CMCM, St. Joseph Regional Medical Center, South Bend, Ind.; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic, Omaha, Neb.; Lynn Handy, CPC, LPN, RevCare Inc., Cypress, Calif.; Emily Hill, PA-C, Hill & Associates, Wilmington, N.C.; Joy Newby, LPN, CPC, Joy Newby & Associates Inc., Indianapolis, Ind.; P. Lynn Sallings, CPC, Area Health Education Center, Family Medical Center, University of Arkansas for Medical Sciences, Fayetteville, Ark.
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.
Send comments to email@example.com.
Editor’s notes: 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.
WE WANT TO HEAR FROM YOU
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 © 2002 by the American Academy of Family Physicians.
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