CODING & DOCUMENTATION

 


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Fam Pract Manag. 2011 Jul-Aug;18(4):36.

Venipuncture

Q

Is venipuncture subject to the “incident-to” rule under Medicare?

No. Direct supervision is not required for venipuncture. It falls under the supervision requirements for diagnostic services. Qualified staff may perform venipuncture under “general physician supervision,” which means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. The training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Six-minute walk test

Q

I want to begin providing the six-minute walk test in my clinic. We plan to mark the hall with a specific number of feet blocked off. We will put a pulse oximeter on the patient's finger and have the patient walk as fast as possible for six minutes. We will measure oxygen and heart rate before, during and at the end of the test. What is the proper code for this? Are there specific documentation requirements?

Your description of the test fits code 94620, “Pulmonary stress testing; simple (e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry).” Your documentation should include pre- and post-test measurements of oxygen saturation (if taken), height, weight, heart rate, blood pressure, notation of rate of supplemental oxygen, if used, patient's time and distance walked, patient ratings of dyspnea and fatigue, and symptoms experienced. If spirometry is performed with the simple pulmonary stress testing, it may not be separately reported. Guidelines for the six-minute walk test published by the American Thoracic Society provide a sample documentation form. You can find the guidelines at http://www.thoracic.org/statements/resources/pfet/sixminute.pdf.

Autism screening

Q

Is there a CPT code to report screening for autism?

Yes. This is typically reported with 96110, “Developmental testing, limited (e.g., Developmental Screening Test II, Early Language Milestone Screen) with interpretation and report.”

Spirometry

Q

Under what circumstances would one code 94375, “Respiratory flow volume loop”? My spirometry equipment includes the loop graph.

You should report 94375. This code represents a more extensive spirometry that includes the loop graph in addition to the components of code 94010, “Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation.” You should not report codes 94010 and 94375 together.

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.

 

About the Author

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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. Bösl, 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, MH

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 © 2011 by the American Academy of Family Physicians.
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