CODING & DOCUMENTATION

 

Fam Pract Manag. 2009 Jul-Aug;16(4):26.

Unbilled services

Q

What services are most commonly overlooked but should be billed for, in your experience?

Services that involve multiple codes seem to create the most confusion. For instance, a medication may be supplied and injected but only one of the two codes gets reported, leaving either the medication or the injection service unbilled. Sometimes services that are not paid for by one or more payers (oximetry, for example) don't get billed at all, even though some insurers do pay for them.

Same-day office visit and observation care

Q

After seeing a two-year-old boy in my office who had failed outpatient hydration therapy and was in need of IV fluids, I admitted him to observation. Later that same date, I saw the patient again, completed hospital orders and dictated the full history and physical. He was discharged the next day. How do I best code both the office visit and the hospital visit that night, which was necessary for the care of the patient? I coded 99217 for the discharge.

Your evaluation and management services on the date of admission to observation should be reported with a code for initial observation care, 99218–99220. The level of service that you report would be based on the total work performed for that patient on that date, both in the office and at other sites of service.

Is transcription an “incident-to service”?

Q

Does transcribing a physician's dictated information qualify as an “incident-to” service?

Transcription does not qualify as a service that would be billed under the incident-to guidelines. While incidental to a physician's service, transcription is included in the practice expense portion of the payment for the service provided.

Same-day preventive and E/M services

Q

The issue of when to bill a problem-oriented evaluation and management (E/M) service with a preventive medicine service is confusing. If chronic problems are stable, should we charge for both services?

It depends on the amount of work necessary to determine whether the chronic problems are stable and whether current management should be continued or adjusted. Preventive services were not valued to include significant physician work related to management of chronic conditions (or acute problems that require the key components of a problem-oriented encounter), so you shouldn't automatically discount this work. One approach is to consider whether the patient would have presented for evaluation of current medical conditions if he or she had not been coming in for the preventive visit. If the answer is yes and the details of the encounter are properly documented, then you should report both E/M codes. If the answer is no, you should only report the preventive service.

Fluorescein eye testing

Q

We perform fluorescein eye testing to check for corneal injury in patients with conjunctivitis. How should we bill for this test?

It should not be separately reported. It is included in the exam component of the service reported.

Editor's note: While this department attempts to provide accurate, useful information, some payers may not agree with the advice given. You should also refer to current CPT and ICD-9 manuals and payer policies.

 

About the Author

Cindy Hughes is the AAFP's coding and compliance specialist and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel, which includes Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Emily Hill, PA-C; Kent Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.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 © 2009 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


MOST RECENT ISSUE


Nov-Dec 2016

Access the latest issue of Family Practice Management

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free FPM email table of contents and e-newsletter.

Sign Up Now