Fam Pract Manag. 2006 Sep;13(8):33-34.
- Pre- and post-op consultations
- Multiple allergy shots
- OB care after hours
- Typhoid immunizations
- Care plan oversight and nursing facilities
- Exam documentation for 99214
- Documenting review of systems
- Billing for Pap smear collections
- STD screening
Pre- and post-op consultations
I performed a preoperative medical evaluation in my office at the request of a surgeon and furnished a written report to the surgeon. Then, while the patient was in the hospital, the surgeon again consulted me regarding the management of problems he felt were beyond his ability. How should I have reported this service? Does it matter whether the reasons for the second consultation were addressed in the pre-op consultation?
An initial inpatient consultation appears to be the correct way of reporting this service to most health plans, provided you gave the physician who requested the consultation a written report documenting your advice on the patient’s treatment. The office consultation would presumably have been in consideration of the patient’s ability to undergo surgery. The inpatient consultation for your advice on management of the patient’s treatment would be separately billable. However, any follow-up care related to this consultation provided on subsequent days should be billed with subsequent hospital care codes – or established patient office visit codes if seen after discharge.
Medicare applies a stricter rule to care in the postoperative period by the physician who provided preoperative consultation. Medicare allows only billing of subsequent hospital care codes for the services.
Multiple allergy shots
If I give two allergy shots to a patient on the same day, should I code 95115 and 95117, or just 95117?
You should code 95117 for two or more injections. Code 95115 should be used only when a single injection is given on a date of service. Code 95117 should be reported just once per patient per date of service.
OB care after hours
When I’m on call, I see walk-in obstetrical patients beyond 20 weeks gestation who come to the labor and delivery department after hours. Should this type of visit be coded as an emergency department visit (99282–99285) with the appropriate modifier, or is there a more accurate code? Also, if a fetal non-stress test is performed, can it be billed in addition to the visit?
While CPT states that antepartum care includes upto 13 visits, labor checks are usually not separately reimbursed from the global period associated with OB care. If you are covering for another physician, the global period applies as it would for your own patient. However, if you provide face-to-face services for complications or preterm labor and the patient does not deliver, you should bill the appropriate evaluation and management (E/M) code. It is important to note whether the patient’s status is observation, inpatient or outpatient. Emergency services codes are used only when the patient is seen in the emergency department. You can report 59025 with modifier -26 for the fetal non-stress test.
What is the procedure code for nonroutine immunization for typhoid?
The CPT codes for the typhoid vaccine (90690–90693) do not indicate routine or nonroutine immunization. You should report the appropriate CPT code along with a diagnosis code that represents the reason for the vaccination. You should also report an administration code from the 90465–90474 series.
Care plan oversight and nursing facilities
I care for about 25 patients in a large assisted living facility. When I talk to the staff by phone about medicines, therapies, referrals or changes in their condition, can I bill for care plan oversight (G0180 or G0181)? If I become the medical director of the facility, will that affect what I am allowed to bill?
Medicare does not cover physician care plan oversight for patients not under the care of home health or hospice. However, when providing care plan oversight in the patient’s home or a domiciliary or rest home (including assisted living facilities) to patients with private insurance, you can bill 99339 and 99340. Physicians who have a significant financial relationship with a home health agency, who are the medical director or employee of a hospice, or who provide services under an arrangement with a hospice can’t be reimbursed for care plan oversight services under Medicare.
Exam documentation for 99214
I’ve seen notes for services billed using 99214 that do not have a documented physical exam. Is coding 99214 appropriate for patient encounters documented in this way?
It could be. Code selection for an established patient office visit should be based on the levels of two of the three key components of E/M services (i.e., history, exam and medical decision making), so it is possible to document only the history and medical decision making and code accordingly.
Codes for these visits may also be chosen based on the amount of face-to-face time if the encounter is dominated by counseling and coordination of care. The face-to-face time associated with a 99214 visit is 25 minutes. If you document that you spent 25 minutes with the patient, indicate that more than half of the 25 minutes was devoted to counseling and describe the nature of the counseling, it might be appropriate to code 99214.
Although a well-documented exam might not be essential for correct coding, it might help to establish the medical necessity of the services you provide and enable better quality of care.
Documenting review of systems
If I perform a complete review of systems with many negatives, is there a short phrase I can use to get full credit for this without listing everything individually?
Medicare’s Documentation Guidelines for Evaluation and Management Services has this to say about a complete review of systems: “At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.”
That said, the Centers for Medicare & Medicaid Services has stated that carriers have the right to interpret the guidelines, and Trailblazers, which is the Medicare carrier for several states, has determined that the notation of “all other systems negative” is no longer permissible. Check with your carrier to find out its interpretation of the rule.
Billing for Pap smear collections
Is it permissible to bill for the collection of a Pap smear separately from a gynecological exam?
CPT includes the collection of a Pap smear in the examination component of an E/M service (problem-oriented or preventive). You should bill the screening Pap collection (Q0091) separately to Medicare because it is one of several preventive services that are a covered benefit under Medicare. You should check with your other payers to determine whether they allow for separate reporting of the Pap smear collection. It is also helpful to know which payers will reimburse code 99000, which is used to report the handling and/or conveyance of a specimen for transfer from a physician’s office to a laboratory.
For more information on billing preventive services, see “Making Sense of Preventive Medicine Coding,” FPM, April 2004.
What diagnosis code should I use for a patient-desired STD/STI screening? Is this different from the code for testing for a presumed illness?
Codes for STD/STI screening should be related to the reason the patient seeks the screening. For instance, use V01.6 for a patient who has been exposed to a venereal disease. Codes V73.88 (screening for chlamydial disease) and V74.5 (screening for venereal disease) may be reported based on risk factors. Additional codes may be appropriate, depending on the patient. Code V15.41 is reported for history of physical abuse (rape), V15.89 for other personal history presenting hazards to health and V69.2 for high-risk behavior. If a patient has no risk factors for the screening, use laboratory examination code V72.6.
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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