Fam Pract Manag. 2003 Sep;10(8):25-26.
- Preventive exam & E/M
- Starred vs. nonstarred procedures
- The elements of an exam
- 99211 for BP & lab
- Coding a nebulizer treatment
- ICD-9 codes for MVA services
- Tuberculosis skin tests
- Consultation codes for pre-operative clearance
Preventive exam & E/M
Patients often present for a preventive exam and also ask for evaluation and management of specific problems (e.g., heartburn, chest pain). Is it appropriate to submit both a preventive medicine services code with a diagnosis code for a general medical exam and an appropriate office visit code with a diagnosis code for the specific problem?
Yes. In the notes preceding the Preventive Medicine Services codes, CPT states that “if an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine [E/M] service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201–99215 should also be reported. Modifier ‘-25’ should be added to the office/outpatient code to indicate that a significant, separately identifiable [E/M] service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.” While some third-party payers will recognize this coding convention, others will not recognize a charge for a preventive medicine visit and an office visit on the same day. Check with your major payers for specific billing instructions.
Medicare recognizes this coding convention but does not cover comprehensive preventive examinations. For this reason, the Medicare patient’s financial obligation for the noncovered preventive service should be reduced by the physician’s current established charge for the office visit when both services are reported, since Medicare considers the services to be two parts of the whole encounter rather than two separate services. Medicare also considers screening pelvic exams (G0101, “Cervical or vaginal cancer screening; pelvic and clinical breast examination”) and screening digital rectal exams (G0102, “Prostate cancer screening; digital rectal examination”) to be potentially covered portions of the encounter, so the patient’s bill for the noncovered preventive service should also be reduced by the physician’s charges for these screening exams.
Starred vs. nonstarred procedures
In the CPT manual, what is the distinction between “starred” procedures (indicated with an asterisk following the code) and “nonstarred” procedures?
The main distinction between starred and nonstarred procedures is that the normal CPT surgical package applies only to nonstarred procedures. Starred procedures involve variable, indefinite pre- and postoperative services that make it difficult to apply the standard CPT surgical package. [For more on CPT’s surgical package, see “Spanning the Global Surgical Package,” page 18.] Accordingly, any pre- and postoperative services associated with starred procedures may be separately reported. Unfortunately, Medicare and some other payers do not recognize this distinction. Note that the starred procedure designation is being eliminated from CPT in 2004.
The elements of an exam
Can I mix and match bullet points from the general multisystem and single organ system examinations in the 1997 Documentation Guidelines for Evaluation and Management Services ?
No. You should not pick and choose from among the elements of different types of exams to satisfy the content and documentation requirements of any one exam type. The bullet points listed under a given exam in the 1997 documentation guidelines apply only to that exam, unless also listed under another exam (e.g., “general appearance of patient” appears under both the general multisystem examination and the cardiovascular examination).
99211 for BP & lab
Is it appropriate to submit 99211 when a patient comes into the office for a blood-pressure check and lab draw?
CPT code 99211 is the appropriate code to use for a blood-pressure check, according to the examples listed for 99211 in Appendix C of the CPT manual. Note, however, that when submitting 99211 for a blood-pressure check, it’s important to ensure that the check is appropriately ordered and medically necessary; otherwise, payers such as Medicare may deny it as a screening service or determine that it is not “reasonable and necessary.” For lab draws, there are specific codes other than 99211 that you can submit (e.g., 36415, “Collection of venous blood by venipuncture” or, for Medicare patients, G0001, “Routine venipuncture for collection of specimen(s)”).When a lab draw and a blood-pressure check are performed and documented on the same day, you may submit the appropriate lab-draw code and 99211 with modifier -25 attached to indicate that there was a significant, separately identifiable E/M service performed on the same date as the lab draw. [For more information on the use of 99211, see “Coding Level-One Office Visits: A Refresher Course,” July/August 2000, page 39.]
Coding a nebulizer treatment
Is CPT code 94640 the appropriate code to use for nebulizer treatment for bronchospasm?
Yes. 94640 is for “pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device),” which includes nebulizer treatment for bronchospasm. When multiple treatments are performed on the same date, this code should be reported for each treatment. Attach modifier -76 to the second and subsequent uses of this code.
ICD-9 codes for MVA services
Which diagnosis codes should I use to designate services resulting from a motor vehicle accident?
For the primary diagnosis, submit the ICD-9 code that reflects the injury(ies) you are diagnosing and treating as a result of the accident. For the secondary diagnosis, submit the appropriate ICD-9 “E” code for motor-vehicle traffic and nontraffic accidents (E810–E825). E codes provide a supplementary classification of external causes of injury and poisoning.
Tuberculosis skin tests
PPD (tuberculosis) intradermal skin tests involve injecting the PPD serum at one visit and examining the site two to three days later to see if any swelling has developed. Do I need to submit the CPT code for the intradermal skin test (86580) on the day the PPD is administered and then interpret the PPD for “free” on a subsequent day as a bundled service; or can I submit 99211 for the interpretation of the PPD by a nurse?
You can submit 99211 if a patient requires subsequent evaluation of a test and no other service is performed. Medicare will also pay for this limited service. Note that if a nurse or other nonphysician provider who is unable to bill for this service under his or her own Medicare provider number performs this service under the physician’s provider number, the “incident-to” requirements must be met. [For more information on Medicare’s incident-to requirements, see “The Ins and Outs of ‘Incident-To’ Reimbursement,” FPM, November/December 2001, page 23.]
Consultation codes for pre-operative clearance
Is it acceptable for a family physician to submit a consultation code for a pre-operative clearance?
Yes, it is acceptable as long as the service meets the definition of a consultation. According to CPT, a consultation is “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” In the case of a pre-operative clearance, the surgeon is typically requesting the family physician’s opinion or advice regarding the patient’s fitness for surgery, especially if the patient has chronic or comorbid conditions that may be relevant (e.g., diabetes, hypertension). If the family physician documents the surgeon’s request, the resulting advice and any services ordered or performed and then provides a written report to the surgeon, it is appropriate to code a consultation for this service.
This coding convention is also recognized by Medicare. For Medicare, be sure to also submit the appropriate diagnosis codes: a code from the V72.81–V72.84 series as the primary diagnosis, the reason for surgery as the secondary diagnosis and any other diagnoses and conditions affecting the patient (e.g., the specific problem evaluated) as the third and subsequent diagnoses. Other payers may follow the same convention, but some may require the relevant diagnoses in a different order (e.g., condition prompting the consult first). For Medicare patients, you may also want to have the patient sign an Advance Beneficiary Notice (ABN) if you believe the service may be subject to a medical-necessity denial. [For more on ABNs or to download a PDF copy of the form, see “Using Advance Beneficiary Notices to Maximize Your Medicare Collections,” FPM, September 2002, p. 19.]
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.
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