Fam Pract Manag. 2004 Feb;11(2):27-28.
- Preventive & E/M services at a new patient visit
- Screening fecal occult
- Time-based coding
- Desferal injection
- Same-day hospital-to-hospital transfer
- Replacing a PEG tube
Preventive & E/M services at a new patient visit
If I perform a preventive medicine service and address a valid medical problem at a new patient visit, should I submit new patient codes for both services?
Yes, because the patient cannot simultaneously be considered new and established from a coding perspective. The notes preceding the preventive medicine services codes in CPT state that "if an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management [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." Remember to add modifier -25 to the office/outpatient code to indicate that it was a significant, separately identifiable E/M service. Note that some payers may still process the office/outpatient code as an established patient encounter, so you should be sure that any code changes made by the payer reflect the same level of physician work as the new patient code you originally submitted.
Screening fecal occult
We've been submitting 82270, "Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 simultaneous determinations," for a screening fecal occult blood test done on a Medicare patient, but we've been getting denied. What code should we be using instead?
You should use G0107, "Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations," instead of 82270. Medicare considers 82270 a diagnostic test rather than a screening test. Note that Medicare will cover G0107 once every 12 months and that the patient must take cards home, obtain samples and return them to you before the coverage criteria described in the Medicare Carriers Manual is met: "Screening fecal-occult blood test means a guaiac-based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools." Obtaining one specimen during the annual exam is insufficient for billing G0107.
How do I code based on time spent counseling patients, and what needs to be documented?
E/M services can be coded based on the time spent counseling the patient when that time constitutes more than 50 percent of the encounter (i.e., more than 50 percent of the face-to-face time you spend with the patient in the office or other outpatient setting or more than 50 percent of the floor/unit time you spend in the facility setting). To choose the correct CPT code, compare the total time spent with the patient with the typical times listed in CPT. For example, if you spend 15 minutes of a 25-minute office visit counseling an established patient, you could code that service using 99214 since the total time spent with the patient (25 minutes) meets or exceeds the typical time listed in CPT for 99214.
Documentation of these visits should include a description of the counseling provided and the total length of the visit. It should also specify that over half of the time was spent in counseling to make it clear that you are coding the encounter based on time rather than other key components (i.e., history, exam and medical decision making). (For more information on time-based coding, see "Time Is of the Essence: Coding on the Basis of Time for Physician Services," FPM, June 2003, page 27.)
What code should I submit for a Desferal injection?
Use HCPCS code J0895, "Injection, deferoxamine mesylate, 500 mg."
Same-day hospital-to-hospital transfer
Since Medicare will typically only pay for one E/M service per day, what code(s) should we submit when the same physician discharges a Medicare patient from one hospital and admits the patient on the same day to a different specialty hospital?
You should only submit a code for the appropriate level of sub-sequent hospital care (99231-99233) performed on the date of the transfer, since the discharge and admission occurred on the same day. The Medicare Carriers Manual addresses this: "Advise physicians that they may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between (1) different hospitals, (2) different facilities under common ownership which do not have merged records, or (3) between the acute care hospital and a PPS exempt unit within the same hospital when there are no merged records. In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer."
Replacing a PEG tube
What code should be submitted if a previously placed percutaneous gastrostomy (PEG) tube comes out on a patient in a nursing home and is replaced by a physician who did not initially place the PEG tube?
CPT code 43760, "Change of gastrostomy tube," should be submitted when this procedure is done by a physician.
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 and 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 Sailings, 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 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.
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