Fam Pract Manag. 2006 Oct;13(9):29-30.
- Calculating face-to-face time
- Billing for medication refills
- Preventive and E/M services at the same visit
- Discontinued procedures
- Neonatal initial critical care
- Defining emergency office services
- Billing for nutritionist services
- Vaccine administration
- Covering for a colleague
Calculating face-to-face time
In regard to billing on the basis of time, does “face-to-face time” only include when I’m actually in the exam room or does it count if I leave the exam room to make a phone call or other arrangements for this patient?
The CPT definition of face-to-face time is defined as “only that time that the physician spends face-to-face with the patient and/or family.” Note that inpatient encounters are different because CPT defines unit/floor time as both time spent at the patient bedside and on the unit/floor rendering services for that patient.
Billing for medication refills
Can established patient level-I codes be used for medication refills performed by a nurse?
Unless your practice provides a medically necessary evaluation and management (E/M) service in addition to the medication refill, you should not use code 99211. Refills alone are not separately reportable services. A level-I nursing visit requires evaluation and management of a patient except when it is billed for an injection provided without direct physician supervision.
Preventive and E/M services at the same visit
If a patient comes in for a well check-up and we find a problem, can we bill for both the well check-up and the additional problem?
Yes. CPT and Medicare state that you may bill for an E/M service on the same date as a well check-up (preventive service). Although some payers bundle these services, many do not. For more information on billing preventive services and E/M services on the same date, see “Same-Day E/M Services: What to Do When a Health Plan Won’t Pay,” FPM, April 2006, and “Making Sense of Preventive Medicine Coding,” FPM, April 2004.
How do I code an attempted endometrial biopsy that was unsuccessful because of a stenotic cervical os?
When a physician discontinues a procedure at his or her discretion and not because of patient instability, it should be reported with modifier -52 attached to show that the procedure was significantly reduced. In this case, you would submit 58100–52 for a discontinued endometrial sampling with or without endocervical sampling and without cervical dilation. The payer will need information on the extent of the procedure that was performed. This information can be submitted in a claim narrative or as a report attached to a paper claim.
Neonatal initial critical care
I admitted a baby who was critically ill to our local hospital for a few hours and then decided to transport him to another hospital with a neonatal intensive care unit. He stayed at our hospital less than 24 hours. What are the rules for using the pediatric or neonatal critical care codes (99293 or 99295)?
Pediatric and neonatal critical care services should be reported by a single physician or single physician group only once per patient per day, regardless of the number of encounters in a given setting. When another physician from a different group provides critical care services on the same day, he or she should report the time-based critical care services (99291–99292) instead. If you or another physician in your group will not be caring for the critically ill patient at the receiving hospital, then either you or the physician at the receiving hospital must bill 99291 or 99292 while the other bills 99293 or 99295. In addition, if you attend the critically ill or critically injured pediatric patient during transport and provide direct face-to-face care, report 99289 for the first 30 to 74 minutes and 99290 for each additional 30 minutes.
Defining emergency office services
Is it appropriate to use 99058 when we work patients into the schedule because of an urgent problem, or must I physically be called out of the exam room to assist a patient in order to use this code?
Code 99058 should be reported when you provide services on an emergency basis in the office that disrupt other scheduled office services. You do not need to be called out of a room to bill 99058, but your scheduled appointments must be disrupted to care for a patient who requires immediate care.
Note also that the diagnosis and chief complaint of the encounter should indicate the emergent nature of the visit. Link 99058 to the diagnosis code that best identifies the reason for the emergency. For instance, say the dentist down the hall phones and asks you to see one of his patients right away for chest pain. You see the patient ahead of other scheduled patients only to determine that he has indigestion. A claim with 99058 linked to a diagnosis code for indigestion is not indicative of an emergency; however, a claim with a primary diagnosis of indigestion and a second diagnosis of chest pain linked to code 99058 is indicative of an emergency.
Be sure to watch payer policies on this code. Medicare and Medicaid typically bundle this code with other services provided, and private payers may limit payment as well.
Billing for nutritionist services
I would like to add a nutritionist to my staff. What is the best way to bill for his or her services?
Use the appropriate code from 97802–97804. These codes should be reported only for services provided by nutritionists. If a physician provides medical nutrition therapy, the E/M or preventive services codes should be used. Private payers may also accept HCPCS codes S9452, S9465 or S9470 for a session of nutrition therapy provided by a nutritionist.
You might also consider offering medical nutrition therapy or diabetes self-management training services for Medicare patients. Medical nutrition therapy may be billed separately as a stand-alone benefit, and dieticians and nutritionists who apply for Medicare provider status can bill for services under both medical nutrition therapy and diabetes self-management training. For these services, you can use a CPT code from the 97802–97804 series, and when additional medical nutrition therapy is ordered in the same year, you can use G0270 and G0271. See Chapter 15, Section 300 of the Medicare Benefit Policy Manual at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf for specifics on diabetes self-management training.
Should I charge a Medicare patient 90701 for a DTP vaccination with 90471 for the immunization administration?
Yes, you would charge for both the DTP and the immunization administration. However, because the DTP is not a covered service under Medicare, it is not necessary to submit a claim to Medicare for these services unless the patient requests it (for example, for the purpose of enabling a subsequent submission of the claim to a secondary insurer). If you do submit a claim to Medicare, include the -GY modifier on your codes to indicate the services are statutorily excluded from Medicare coverage. It is a good idea to provide the patient with a Notice of Exclusion from Medicare Benefits (NEMB), which is intended to ensure the patient understands that the service is not a covered benefit under Medicare Part B. This form is available in English and Spanish at http://www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp.
Covering for a colleague
If I am covering for another physician and see some of her patients during her absence, are these patients considered new or established?
CPT specifically addresses this in the E/M services guidelines section in the front of the CPT manual, under the heading “New and Established Patient”: “In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.”
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 © 2006 by the American Academy of Family Physicians.
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