Fam Pract Manag. 2010 Jul-Aug;17(4):33.
Preventive care visit + procedure?
Can I add modifier 25 to my preventive visit code if I perform another procedure the same day, such as an electrocardiogram?
Unless your payer has a specific rule that requires it, the addition of modifier 25 is not necessary. CPT guidance for preventive service codes 99381-99397 states, “Vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests … identified with a specific CPT code are reported separately.”
23-hour observation stay
According to CPT, 99218–99220 plus 99217 are for admission and discharge on two separates dates of service, and 99234–99236 are for admission and discharge on the same date of service. So how should I code a 23-hour observation stay?
The dates of service – not the length of stay – determine the code selection. It may be necessary to submit two separate codes even if the patient is in observation status for less than 24 hours. For example, services provided to a patient admitted at 11 p.m. and discharged at 9 a.m. the next day would be reported with the appropriate code in the 99218–99220 series for initial observation care on the first day and 99217 for observation discharge services on the second day, even though the observation stay was just 10 hours long.
When reporting the admitting physician's E/M services, keep in mind that Medicare guidelines do not allow reporting 99234–99236 or 99217 for stays of less than eight hours. Instead report a code from the 99218–99220 series. For more information on Medicare guidelines for billing observation care services, see Chapter 12, Section 30.6.8 of the Medicare Claims Processing Manual.
Defining new patients in a group practice
The family physicians who work in our hospital network's urgent care centers and primary care practices share the same tax ID number. Are we considered part of the same group? Let's say a patient has an initial encounter at one of the urgent care centers. The family physician working at the urgent care center treats the patient but suggests she get a primary care physician. The patient comes to my office for an initial visit and physical, and I begin treating her chronic conditions. Can I bill a new patient visit, or must I use an established-patient visit code?
CPT defines an established patient as someone who has received services from the physician or another physician in the same group and of the same specialty within the prior three years. In the scenario you present, the patient is established. The tax ID number defines the group practice, so you and the family physician practicing at the urgent care center belong to the same group.
To help identify which physicians in your group are in the same specialty, it may be helpful to maintain a list of the specialties they designate on their Medicare enrollment applications. Medicare's physician specialty codes can be found at https://www.cms.gov/MedicareFeeforSvcPartsAB/Downloads/SpecialtyCodes2207.pdf.
Editor's note: While this department attempts to provide accurate, useful information, payers may not accept the advice given. Refer to current coding 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 email@example.com, 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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