Fam Pract Manag. 2006 Jul-Aug;13(7):25-26.
- Billing for group visits
- Multiple physicians for one patient
- Communicating with nursing home staff
- Laser therapy
- “Get-acquainted” visits
- Wound repair
- E codes as secondary diagnoses
- Telephone counseling
Billing for group visits
Our office is planning to conduct diabetes group visits. We plan to obtain personal medical histories, review systems, check vital signs, review current medications, offer point-of-care lab testing and personal goal-setting, change medication doses when necessary, write new prescriptions and give referrals when appropriate. We also plan to write individual progress notes for each patient. Would it be appropriate to bill 99213 or 99214, along with 99499, “Unlisted evaluation and management (E/M) service,” if our documentation meets the criteria for these codes?
At this time, there is no clear guidance from CPT for coding group visits. If you do in fact see patients individually in addition to the group session, you can submit an office visit code with 99499. Keep in mind that the level of service you bill must reflect only the care provided in the individual encounter, and your documentation must distinguish between the care provided as part of the group visit and the care provided as part of the individual encounter. If you don’t see patients individually, ask your payers for written instruction about how to bill for the group visits you provide.
You may also want to consult the Medicare Benefit Policy Manual, which describes Medicare’s coverage of group medical visits for diabetes self-management training services (see section 300 in http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf). Where state law requires that employer insurance plans cover diabetes self-management education, some private payers may cover these services as well. In these situations, use code 99078, “Physician educational services rendered to patients in a group setting (e.g., prenatal, obesity or diabetic instructions).” See “Group Visits for Chronic Illness Care: Models, Benefits and Challenges,” FPM, January 2006, for more information.
Multiple physicians for one patient
I recently admitted a young patient with monoarthritis. Later, I consulted a rheumatologist to aspirate the joint and diagnose septic arthritis, after which I also consulted a surgeon and an infectious disease specialist. Can each of us bill for the services we provided if we use the same diagnosis?
As long as there is no duplication of services, each physician should be reimbursed for his or her services, assuming they are considered medically necessary. In your example, you would bill for the initial inpatient history and physical examination and any follow-up inpatient hospital care, such as daily visits and discharge services. The other physicians would bill for the consultations, the aspiration and all related services. Should you and one of the other physicians whose services are not included in a surgical global period provide follow-up care for the same diagnosis on the same date, the service may be denied as concurrent care. This would require that both physicians send records to justify the need for the services. For more on concurrent care, see “A Refresher on Medicare and Concurrent Care,” FPM, November/December 2005.
Communicating with nursing home staff
Can I use care plan oversight codes for my communications with nursing home staff regarding the management of my patients there?
Medicare does not separately reimburse for services related to communication with nursing home staff. These services are included in the E/M services provided to the patient. Some private payers might reimburse separately for these services if they are the primary payer, but it is unlikely that many nursing home residents have private insurance as a primary payer. If the private payer is secondary to Medicare, check with the payer to determine the coverage policy. The codes for billing private payers for physician supervision of a nursing facility patient are 99379 and 99380.
I have tried billing Medicare for low-level laser therapy with CPT code 97032. Medicare has denied the code, saying a modifier must be submitted. Sometimes we include an office visit on the claim, depending on the time spent with the patient and the services performed. How should we be coding for these services?
Correct billing for constant attendance by the provider of low-level laser therapy would be 97039, “Unlisted modality.” Without constant one-on-one attendance by the provider, code 97799, “Unlisted physical medicine/rehabilitation service or procedure,” should be reported. Code 97032, “Application of a modality to one or more areas; electrical stimulation (manual),” is used to report constant attendance for electrical stimulation. Because low-level laser therapy is not an electrical stimulus, it should not be reported with this code.
Your Medicare carrier may have a local coverage determination on low-level laser therapy, although many carriers have denied coverage of this therapy as not yet substantiated by scientific evidence. If your carrier does not cover it, your patient must sign an Advance Beneficiary Notice before you can bill for the service.
When billing for a significant, separately identifiable E/M service on the same date as the low-level laser therapy, append modifier –25 to the E/M code.
Is there a code for a “get-acquainted” visit with a new patient?
No. These services would not be considered medically necessary or preventive and should not be billed to the insurance. Unless your policy is to provide these visits at no charge, patients should be informed when they call to schedule this type of visit that insurance will not cover it and that payment will be expected at the time of service.
A patient presented with an open leg wound that required simple repair. The care of the wound became complicated, however, because the patient could not clean and redress the wound himself. The patient came in for the next six days for cleaning, application of topical medication and redressing. After six days, the wound finally began to heal. How should I code this care?
Unfortunately, you can’t be reimbursed for these services because the wound repair codes typically have a 10-day global period. Medicare and most payers will deny any related services during the global period except those related to a complication that requires a visit to the operating room.
E codes as secondary diagnoses
I recently saw a patient who had bilateral knee pain from a car accident where he struck his knees on the dashboard. I coded knee pain, 719.46, as the primary code for the visit (X-rays were negative for fracture), and E813.0, “motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle,” as the secondary code. His insurance denied the claim, indicating that the E code was the cause for the denial. I thought E codes were used as descriptors that do not affect the reimbursement of the primary code. Can you explain?
You are correct to code E813.0 secondary to 719.46. It could be that the E code has alerted the health plan that an automobile insurance company should be the primary payer on this claim. Accident-related claims often need to be filed with the automobile insurance company before they will be considered for payment by the patient’s health plan. You should contact the health plan to ask about the reason for the denial.
I recently was authorized by a private payer to provide telephone counseling to a mental health patient. Can you tell me how to bill for a one-hour session?
Both outpatient E/M codes and psychotherapy codes require face-to-face contact, according to CPT. In this instance, I would recommend asking for written instructions from the payer on how the company wants the service reported. There are codes for telephone calls with patients, but these are generally not covered by any payer and do not adequately describe counseling services.
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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