Fam Pract Manag. 2003 Oct;10(9):16.
The questions and answers featured in this installment of Coding & Documentation address subjects we tend to get asked about again and again. Each item was previously published in FPM.
G0101 & E/M services
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 0101 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 check-up 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.
99211 for strep screens
When patients ask for a strep screen, a nurse administers it and we only charge for the strep screen itself. If the test is positive, a physician prescribes an antibiotic. What would make the nurse’s visit a separately identifiable service from the strep screen and allow a 99211 charge?
CPT considers 99211 to cover the “evaluation and management” of an established patient in the office or other outpatient setting. Although the use of 99211 does not involve any particular level of history, exam or medical decision making, it still requires some “evaluation and management” of the patient. In your example, to make the nurse’s visit a separately identifiable service, the chart would need to indicate that the nurse did something more than just administer the strep screen to the patient (e.g., noting a chief complaint or any elements of the history of present illness, taking and recording any vital signs or recording observations). Notations such as these would help establish “evaluation” of the patient. Additional notations reflecting the results of the screen and follow-up action planned (e.g., “strep screen positive; doctor prescribed antibiotic” or “strepscreen negative; symptomatic treatment only”) would help establish “management.” Note that if this is a Medicare patient, the nurse’s service must also meet Medicare’s “incident-to” guidelines to be a billable service.
Billing for nursing home work
For my nursing home patients, I would like to bill for the time it takes me to answer the staff’s questions, write the orders and do all of the paperwork for the patients. Although Medicare has care plan oversight codes, apparently these activities are not billable for nursing home patients. Is there any other way I can bill for this time-consuming care?
Unfortunately, no. Medicare takes the position that payment for care plan oversight services provided to nursing facility patients is already bundled into the payment it makes for the nursing facility visits and other E/M services provided to these patients. Because Medicare views these services as “bundled,” it does not permit the physician to separately bill the patient for them.
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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Send questions and comments to email@example.com, 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 © 2003 by the American Academy of Family Physicians.
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