CODING & DOCUMENTATION

Answers to Your Questions

 

Fam Pract Manag. 2002 Nov-Dec;9(10):30.

Hospital observation/admission/discharge

Q

If I admit a patient in the morning for chest pain, rule out MI and discharge the patient that evening, should I submit the appropriate hospital observation code or the appropriate same-day admission/discharge code? In the same situation, if I admit the patient in the evening and discharge the patient the next morning, should I submit hospital observation codes or the regular admission/discharge codes?

If you admit a patient in the morning for observation or as an inpatient and then discharge the patient that same evening, you should use the appropriate same-day admission/discharge code (99234-99236), since these codes are used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. Note that Medicare requires the patient to be an inpatient or an observation care patient for a minimum of eight hours on the same calendar date to submit these codes; the physician should document the time in the patient's medical record. When the patient is admitted as an inpatient or an observation care patient for fewer than eight hours on a calendar date, Medicare requires that you submit codes only for initial observation care (99218-99220) or initial hospital care (99221-99223), as appropriate.

If you admit a patient in a face-to-face encounter in the hospital on one date and discharge the patient on the next date, you should submit the appropriate initial observation care code or initial hospital care code (depending on the type of admission) for the first date of service and either the corresponding observation care discharge code (99217) or hospital discharge code (99238 or 99239) for the second date.

G0101 & E/M services

Q

I have been told that, with appropriate documentation, an office visit code can be billed in addition to G0101, “Cervical or vaginal cancer screening, pelvic and clinical breast examination,” for an annual gynecologic exam for a Medicare patient. However, my billing department does not agree. Can you please clarify this?

Medicare will allow you to submit G0101 in addition to an evaluation and management (E/M) service (e.g., 99213) if the E/M service is significant and separately identifiable from the G0101 service. An example would be if an established Medicare patient with chronic essential hypertension on a multiple-drug regimen presents for a periodic checkup of her condition, you note that the patient is overdue for a screening pelvic and breast exam and you perform the screening exam while the patient is in the office at that visit rather than having her return solely for the screening exam.

You will need to attach modifier-25 to the E/M service code and, as noted, provide appropriate documentation if questioned. Be sure to link the appropriate ICD-9 code (e.g., V76.2) to the G0101 service and link the problem-oriented ICD-9 code to the E/M visit.

If the E/M service is not problem-oriented but rather a comprehensive preventive medicine service, the appropriate preventive medicine code should be reported in addition to G0101. Since Medicare does not cover comprehensive preventive medicine services, the patient will be responsible for the difference between your established charges for the E/M service and the G0101 service.

ICD-9 code for tobacco dependence

Q

Is there an ICD-9 code for tobacco dependence?

Code 305.1, “Tobacco use disorder,” includes tobacco dependence. Note that there is a separate code for history of tobacco use (V15.82).

Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.

Conflicts of interest: none reported.

Editor's note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. 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 fpmedit@aafp.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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