CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2005 Mar;12(3):27-28.
- Coding forms completion
- An office visit with multiple procedures
- Venipuncture on a Medicare patient
- Coding a pre-operative, consultative exam
- Trigger-point injections
- Interpreting diagnostic tests
- Critical-care transport
- “Reviewing” vs. “interpreting” an X-ray
Coding forms completion
Under what circumstances is it appropriate to submit 99080, “Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form?”
Code 99080 is intended to be used when a physician fills out something other than a standard reporting form, such as paperwork related to the Family and Medical Leave Act. This code does not apply to the completion of routine forms, such as hospital-discharge summaries. Also note that it would not be appropriate to submit 99080 in conjunction with 99455 or 99456, which are the codes for work-related or medical disability evaluation services. The descriptors for these codes explicitly state that they include “completion of necessary documentation/certificates and reports.”
An office visit with multiple procedures
What code(s) should I submit when I perform multiple procedures and an evaluation and management (E/M) service at the same visit?
When multiple procedures are done at the same visit, you should report the primary procedure as listed in CPT. This is typically considered to be the procedure with the most relative value units (RVUs) in the Medicare fee schedule. Additional procedures may be identified by attaching modifier -51, “Multiple procedures,” to the corresponding CPT code(s), unless the CPT manual indicates that the code(s) is modifier -51 exempt or is an add-on code. If a significant, separately identifiable E/M service is done at the same encounter, you may submit a code for it as well. If the procedures are minor (e.g., benign skin lesion excision), attach modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” to the E/M code. If the procedures are major (e.g., fracture care), consider attaching modifier -57, “Decision for surgery,” to the E/M code. In either case, your documentation should clearly establish the separate nature of the E/M service, and you may even want to write a separate note for the E/M service.
Venipuncture on a Medicare patient
What code should I submit for venipuncture done on a Medicare patient?
You should use CPT code 36415,“Collection of venous blood by venipuncture.” Prior to this year, Medicare had its own HCPCS code, G0001, “Routine venipuncture for collection of specimen(s),” for this service.
Coding a pre-operative, consultative exam
At the request of an orthopedic surgeon who was preparing to perform a simple orthopedic procedure on a 30-year-old patient, I performed a detailed preoperative exam on the patient, who ended up having no other health concerns, a normal exam and a normal hemoglobin. Would it be appropriate to submit a consultation code for my exam in this case?
If the orthopedic surgeon was requesting your opinion on the patient’s fitness for surgery and you shared your opinion or advice with the orthopedic surgeon in writing, you may submit the appropriate consultation code (99241–99245). Otherwise, you should submit an appropriate office or outpatient visit code based on the history, exam and medical decision making involved, as you suggested, assuming the service was done in your office or another outpatient setting. Note that some payers may not consider this service medically necessary. If you suspect this may be the case, you may want to warn the patient that this service may not be covered and even consider having the patient sign a payment responsibility waiver prior to providing the service.
What code(s) should when I perform trigger-point I submit injections at an office visit?
You should submit 20552 “Injection(s); single or multiple trigger point(s), one or two muscle(s),” or 20553, “... three or more muscles.” The code is based on the number of muscles injected, not the number of injections given. Note that you should only submit 20552 or 20553 once per session since either code covers multiple injections. Also note that you should clearly document the location of injections, number of injections and number of muscles involved. If you also perform a significant, separately identifiable E/M service at the same visit, you should attach modifier -25 to the appropriate E/M code.
Interpreting diagnostic tests
After initially seeing a patient face-to-face, I sometimes interpret a diagnostic test by mail. This can be quite complicated, taking an hour or more to prepare. What code should I submit for this service?
When you provide the interpretation and written report (i.e., the professional component) for a diagnostic test, you should submit the code for the test and attach modifier -26, “Professional component,” or submit the appropriate CPT code for the professional component of the test. For example, if you interpreted and provided a written report on a single-view chest X-ray taken outside your office, you would submit 71010, “Radiologic examination, chest; single view, frontal,” with modifier -26 attached. This indicates that you provided the professional component of the X-ray while someone else provided the technical component. If you interpreted and provided a written report on a routine ECG, you would submit the CPT code for that service, 93010, “Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.”
Note that if you are simply reviewing test results that have already been interpreted or reinterpreting the technical component of a test that has already been interpreted by someone else, you are not providing a separately reportable service. Such a review is considered part of the E/M service.
What code(s) should I submit for accompanying a 15-month-old critical-care patient during transport from one hospital to another? I spent one-and-a-half hours with the patient in the first hospital, two hours transporting the patient to the other hospital and 30 minutes with the patient in the second hospital.
Assuming that all of the services you performed otherwise met CPT’s definition of critical care services, you should submit the pediatric critical-care patient transport codes 99289 and 99290 for the face-to-face time you spent with the patient. This time should begin when you assumed primary responsibility of the patient at the referring hospital and end when the receiving hospital accepted responsibility for the patient’s care. Code 99289 is for the first 30–74 minutes, and code 99290 is for each additional 30 minutes. Since you spent a total of four face-to-face hours with the patient, you should submit 99289 once and 99290 six times. (Note that if the patient were older than 24 months, you would code the time spent providing critical care services to the patient with 99291 for the first 30–74 minutes and 99292 for each additional 30 minutes.) Then, for any services you provided after the patient was admitted to the receiving hospital, you should submit the appropriate inpatient pediatric critical care code (99293 or 99294).
“Reviewing” vs. “interpreting” an X-ray
In the Documentation Guidelines for Evaluation and Management Services, the following statement appears in the section about the “amount and/or complexity of data to be reviewed”: “The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.” With this in mind, if I review an X-ray that I ordered and a radiologist officially interprets it, would I get one or two points for the interpretation, according to standard E/M coding tools, such as FPM’s Pocket Guide to the Documentation Guidelines?
If you review the X-ray and provide and document your own interpretation of it in a written or dictated report as appropriate for a radiologic interpretation, you have fulfilled the intent of the documentation guideline you quoted and would qualify for the two points assigned to such an independent interpretation in standard E/M coding tools. However, if you only order the X-ray and/or review the interpretation provided by the radiologist, you would only qualify for one point toward scoring the “amount and complexity of data to be reviewed.”
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.
Copyright © 2005 by the American Academy of Family Physicians.
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