CODING & DOCUMENTATION
Fam Pract Manag. 2006 Feb;13(2):30-31.
- Emergency care outside an ED
- Modifiers for multiple births
- History and physical for hospital readmittance
- Home health certification
- Materials for fiberglass splints
- Coding pelvic exams and Pap smears
- 99173 with an E/M service
Emergency care outside an ED
We are a small, rural health center that sees patients for regular office visits and emergent issues (the nearest hospital is 75 miles away). Which codes should we be using to code the emergency visits?
It sounds like your site would not be considered an emergency department, according to the CPT definition: an organized hospital-based facility available 24 hours a day to provide unscheduled episodic services to patients who need immediate medical attention. So you should code 99058 for office services provided on an emergency basis. This should be billed in addition to the evaluation and management (E/M) code. If your clinic is a designated rural health center for Medicare or Medicaid, you may not bill the emergency office-visit code as it is bundled with the other services provided in the visit.
Note that 99058 is only to be used when, in the physician's judgment, the “emergency” warrants interrupting the care of other patients. This code is not to be used for urgent care slots or work-in appointments (see codes 99050-99051 for care provided on evenings, weekends or holidays). If prolonged services are provided, these may be billed in addition to the codes for the E/M and the emergency services. Critical care services provided for 30 minutes or more may be billed with codes 99291-99292. Medicare does not allow reimbursement of both an E/M service and critical care service code when provided at the same visit.
Modifiers for multiple births
What CPT code should we use when billing for multiple births?
There are several accepted ways of billing for multiple births. The most common is to bill the appropriate global obstetric care code or delivery-only code with modifier −22, “Unusual procedural services.” However, it is also acceptable to most carriers to bill the global obstetric code or delivery-only code for the first baby and to bill the delivery-only code with modifier −51, “Multiple procedures,” for additional births.
If one child is born by vaginal delivery and one by cesarean delivery with global care provided by the same physician or physician group, code the global package for the cesarean delivery and report the delivery-only code with modifier −51 for the vaginal delivery. When all births are by cesarean section, code the appropriate cesar-ean global code or delivery-only code with modifier −22, as many payers will not pay two cesarean codes because there is only one incision.
History and physical for hospital readmittance
If a patient is admitted, discharged and readmitted to the same hospital within a 24-hour period but with a different diagnosis, can I charge for another brief history and physical?
Nothing in the CPT manual precludes billing for this service. As you suggested, a brief history and physical may be all that is necessary unless the patient is being admitted for a complex new condition, such as injuries from an accident. You may want to consult with the insurance companies you contract with to determine their regulations.
Home health certification
What requirements must be met to bill Medicare and other insurers for home health certification and recertification (G0179 and G0180)?
To bill Medicare for the services described by codes G0179 and G0180, you must meet the Centers for Medicare & Medicaid Services' guidelines. For G0180, the patient must not have been under home health care for at least 60 days. You should document your time spent developing care plans, reviewing subsequent reports of the patient's status, reviewing lab tests or other study reports, communicating with health care providers not in your practice who are involved in the patient's care, and integrating new information into the patient's treatment plan or adjusting medical therapy. Each certification period is 60 days.
Note that where other payers are involved, you should report these services with care plan oversight codes 99374 and 99375, because most private payers won't provide reimbursement for G codes.
For more information about home health certification, see “An Update on Certifying Home Health Care,” FPM, May 2001.
Materials for fiberglass splints
What code should I use to get reimbursed for the materials for fiberglass splints I apply in the office?
For Medicare and most private payers, fiberglass splints fall under the HCPCS Q codes. Codes Q4001-Q4051 contain codes for both plaster and fiberglass splints and depend on the age of the patient and site of application. You could also bill the splints to private insurance using code 99070, “Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies or materials provided).”
Coding pelvic exams and Pap smears
How should I code for visits limited to gynecological exams and screening Pap smears for Medicare and private payers?
For Medicare, use HCPCS code G0101 to report a pelvic and breast examination, which is covered once every two years for low-risk patients (those with diagnosis V76.2, V76.47, V76.49). This service is covered annually for high-risk patients, whose diagnosis would be V15.89.
The screening Pap is covered once every two years for low-risk patients and annually for high-risk patients. Use code Q0091 to report obtaining and preparing a screening Pap smear test and conveying it to a lab, and use G0124, G0141 or P3001 for interpreting the results. Diagnosis code V72.31 is a covered diagnosis for Medicare beneficiaries undergoing a screening Pap and full gynecological exam. For more information on Medicare's preventive services, see http://www.cms.hhs.gov/PrevntionGenInfo/.
Many private payers will want the gynecological exam and Pap smear billed as a preventive service with codes 99381-99397. Some may accept code 99000 for the preparation and transfer of the specimen to the lab. For more information on billing for preventive services, see “Making Sense of Preventive Medicine Coding,” FPM, April 2004.
99173 with an E/M service
We are getting denials for code 99173, Screening test of visual acuity, quantitativebilateral,” when we bill in conjunction with E/M codes. We append modifier −25 to 99173. Are we billing this correctly?
When billing for a separately identifiable service on the same date as an E/M service, the modifier −25 should be appended to the E/M code (for instance, 99213-25.) Payers may choose to bundle code 99173 with the E/M service despite the correct modifier usage. You should check with your payer to determine if this service is separately billable and how it should be coded. Also note that 99173 is for a screening exam and should not be billed for an ophthalmologic service or an E/M service of the eye.
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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.
Copyright © 2006 by the American Academy of Family Physicians.
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