Fam Pract Manag. 2007 Oct;14(9):15-16.
- Determining the chief complaint
- Biopsy vs. excision
- Billing for a hospital discharge
- Follow-up visits and global periods
- Swing bed care
- E/M visit + vaccination
- Assessment after a car accident
- Billing for teaching rounds
Determining the chief complaint
We have been advised that we cannot bill a level-III or level-IV office visit unless the patient has a chief complaint. Is this accurate? What is considered the chief complaint for patients with chronic conditions who need periodic visits to be sure their health is stable?
A chief complaint is required for all non-preventive evaluation and management (E/M) services. Stable conditions that require medically necessary follow-up do meet the definition of chief complaint. A chief complaint is a concise statement of the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. The chief complaint of a patient coming in for follow-up care could be described as, “Patient returns for re-evaluation of diabetic control as per doctor's order at last visit.”
Biopsy vs. excision
How should I determine when to report a punch or shave biopsy rather than excision of a lesion?
When tissue is obtained solely for the purpose of pathological examination, you should report biopsy codes 11100–11101 or codes 11300–11306 for a shave biopsy. An excision includes removal of the lesion including full-thickness (through the dermis) and appropriate margins. Pathological examination may well be performed on the excised tissue, but because this is not the only purpose of the procedure, a lesion excision should be reported rather than a biopsy code.
Billing for a hospital discharge
When I admit patients to the hospital, sometimes I do not see them again until discharge because they have been in the care of several other specialists. I fill out the necessary paperwork and submit the proper discharge code to the payer. Is it appropriate for me to bill for the discharge even if I didn't see the patient after admission, aside from an occasional courtesy visit?
It depends on whether you provide a medically necessary hospital discharge service or merely complete paperwork required by the facility. Per CPT, the hospital discharge service codes (99238–99239) include the following, as appropriate: “final examination of the patient, discussion of the hospital stay, even if the time spent on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.” This does not necessarily indicate that a face-to-face service to the patient is required. However, Medicare and many other payers require a face-to-face encounter with the patient when reporting E/M services.
Follow-up visits and global periods
We perform some outpatient procedures in our office, such as nuclear stress tests, and some in the hospital, such as colonoscopies. Can we be reimbursed for a follow-up office visit associated with an outpatient procedure?
This depends on the global period that the payer has assigned to the procedure. Procedures typically are assigned a zero-, 10- or 90-day global period. Followup visits in the global period are not separately reportable. Unlike invasive or surgical procedures, most testing procedures are not assigned a global period. To learn the global periods assigned by Medicare, you can search codes in the Medicare Physician Fee Schedule Look-up at http://www.cms.hhs.gov/PFSlookup/02_PFSSearch.asp or you can access the Medicare Physician Fee Schedule Relative Value Files to review all codes at http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp. Many commercial payers use the same global periods assigned by Medicare, but you should check with your payers and state Medicaid to verify their policies.
Swing bed care
I currently see multiple patients under swing bed care. I know that I need to use skilled nursing facility codes for this if the patient's status is classified as swing bed. Can I bill each time I see the patient, or am I allowed only a limited number of visits?
E/M visits that are reasonable and medically necessary to meet the needs of the individual patient (i.e., unrelated to any state requirement or administrative purpose) are payable under Medicare Part B. Note that the federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises (e.g., the patient has health problems that need attention on the day the mandated physician E/M visit occurs). When seeing patients during rounds, ask yourself, “If seeing this patient required a separate trip, would I feel it was medically necessary to make that trip?” If not, consider whether the visit should be provided as a courtesy.
You should report only one E/M visit per day because the descriptor for each of the nursing facility codes includes the phrase “per day.” Claims for an unreasonable number of daily E/M visits by the same physician to multiple patients at a facility within a 24-hour period may result in medical review to determine medical necessity. Remember that the E/M documentation guidelines apply to these visits.
E/M visit + vaccination
If I perform a level-III problem-oriented office visit and then give the patient a hepatitis A injection, can I bill for the visit (99213), the vaccine (90632, Hepatitis A vaccine, adult dosage, for intramuscular use) and the vaccine administration (90471) at the same time?
Yes. You will need to append modifier -25 to code 99213 in this scenario to indicate that your work during the E/M service was significant and separately identifiable from the work of administering the vaccine.
Assessment after a car accident
A patient came to see me shortly after he was involved in a one-car motor vehicle accident. He had been seen at the emergency department (Ed), and they could not find health reasons for the accident. The patient needed me to complete forms for the motor vehicle department so that he could maintain his driver's license. At the visit, he informed me that he is bipolar and hypoglycemic. How should I code this office visit?
Although the patient is asking you to complete a form, he is also presenting with a problem. You should report any E/M services you performed in addition to any laboratory testing or other services. Although the ED found no health reasons for the accident, it is reasonable for you to provide further evaluation of injuries sustained in the accident as well as assess the coexisting conditions of bipolar disorder and hypoglycemia and determine whether these might affect the patient's fitness for driving.
The diagnosis codes should include those for the patient's conditions and the E code that best describes the accident that occurred (e.g., E816.0, “Motor vehicle traffic accident due to loss of control, without collision on the highway; driver of motor vehicle other than motorcycle”).
Be sure to include the date of the accident on the health insurance claim. You should also collect information about the patient's automobile insurance in case you need it later. The health plan may not process the claim without a statement from the auto insurance agent stating either that no claim was filed on that policy or that the benefits have been exhausted.
Billing for teaching rounds
I am a physician at a teaching hospital, and I regularly make teaching rounds with residents. does Medicare allow me to bill for this?
You may bill for the services as long as you either personally perform them while the residents watch or you are physically present in the patient's room when the resident performs the key or critical portions of the service. Chapter 12, Section 100.1.1 of the Medicare Claims Processing Manual explains the rules for this. You can access this chapter online at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.
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