Jan-Feb 2010 Table of Contents

CODING & DOCUMENTATION

Fam Pract Manag. 2010 Jan-Feb;17(1):32-33.

Diagnosis code order

Q

I recently saw a patient for a complete physical. He had several pain-related complaints. Which diagnosis code should I list first? Should it be V70.0, “Routine general medical examination at a health care facility”?

A

The guidelines for ICD-9 coding state: “List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.”

So you'll need to decide which condition was chiefly responsible for your services and list this diagnosis code first. List codes for the other diagnoses next, being certain to link each one to the related CPT code. In your example, you should link V70.0 to the preventive medicine services, and link the diagnosis codes for pain to the problem-oriented evaluation and management (E/M) code, if the work was significant to warrant billing separately for it.

STD screening requested by patient

Q

What ICD-9 code should I use for a patient-desired screening for a sexually transmitted disease or infection (STD/STI)? Is this different from the code for testing when an STD/STI is presumed?

A

Codes for STD/STI screening should be related to the reason the patient seeks the screening. Use diagnosis code V01.6 for “contact with or exposure 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, including V15.89 for other personal history presenting hazards to health and V69.2 for high-risk behavior.

Immunizations provided by a nurse

Q

How should I code for immunizations provided in the context of a well-child exam? My nurse usually administers the vaccine.

A

Use immunization administration codes 90465–90468 when you counsel a patient or family of a patient younger than 8 years old about the vaccine. Use codes 90471–90474 when physician counseling is not provided or the patient is 8 or older. None of these codes require that the physician administer the vaccine. Office staff working incident-to the physician may administer the vaccine. Don't forget to code for the well-child exam and vaccine as well.

Exam documentation needed for 99214?

Q

Is documenting a physical exam required in order to code 99214?

A

The established patient office visit code you bill 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. Although a well-documented exam might not be essential for correct coding, it may help to enable better quality of care and, when coding based on key components, it will help establish the medical necessity of your services.

Pap smear collections

Q

Is it acceptable to bill for a Pap smear collection separately from a gynecological exam?

A

CPT includes the collection of a Pap smear in the examination component of a problem-oriented or preventive E/M service. 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. Consult your other payers to determine whether they pay separately for the Pap smear collection and also for 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.

Office visit with patient's parent

Q

I had an office visit with the father of a patient to discuss the teenage patient's chronic illness. (I got permission from the patient prior to the visit to discuss this with his father.) Should I bill this as a service to the father or to the son, and as an office visit or consultation?

A

It depends on the payer. CPT defines the counseling component of an E/M service as a discussion with a patient and/or family concerning one of several areas described in the definition. One of the areas is prognosis, and another is risks and benefits of management options. However, Medicare and some other payers require that E/M services include face-to-face services with the patient. Contact your payers to determine how best to bill for these services. If the patient's health plan won't reimburse you for the services, the father's health plan might. If you bill the counseling service to the father's insurer, consider using diagnosis code V61.49, “Other health problems within family,” and an E/M code based on the documented time spent counseling.

ICD-10 timing

Q

When do we have to begin using ICD-10 for reporting diagnoses?

A

The ICD-10 code set will replace ICD-9 on Oct. 1, 2013. For a preview of ICD-10 diagnosis codes, see http://www.cdc.gov/nchs/icd/icd10cm.htm. There is an earlier, related deadline to be aware of as well. By Jan. 1, 2012, practices must implement the 5010 HIPAA-compliant electronic transaction standards, which will provide the identifiers necessary for transmitting ICD-10 codes.

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 © 2010 by the American Academy of Family Physicians.
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