Fam Pract Manag. 2013 Sep-Oct;20(5):32.
- Modifier 25
- Emergency department visits
- Transitional care management and Medicare Advantage
- Transitional care and length of stay
- Health coaching
If a patient has more than one chief complaint, can I use modifier 25 for one of them when I submit my codes?
No. The chief complaints are not treated as separate evaluation and management (E/M) codes. If the number and complexity of the problems increase your history, exam, and medical decision-making, you may be able to report a higher level of code than if you were addressing a single chief complaint. However, you should typically report only one E/M code for the encounter.
Emergency department visits
As a patient's primary care physician, if I see a patient in the emergency department (ED) but that visit was not requested by the attending ED physician, how should I bill the visit?
If you are the only one seeing the patient, bill the appropriate ED service code (99281-99285). If the ED physician has already evaluated the patient and then calls you in for an opinion or recommendation regarding care of the patient, bill an outpatient consultation code (99241-99245), but not if the patient is a Medicare beneficiary. In that case, bill Medicare using the appropriate new patient or established patient codes (99201-99205 or 99212-99215). Be sure to use the place-of-service code, 23, to signify emergency room-hospital. If you were not consulted by the ED physician and he or she already evaluated the patient, you may not be paid for your visit.
Like most E/M codes, the ED codes and the consultation codes are based on the level of history, exam, and medical decision-making involved. However, CPT makes no distinction between new and established patients, and all three key components must be met to report a given level of service.
Transitional care management and Medicare Advantage
Do the transitional care management codes apply only to Medicare, or do they also apply to the Medicare Advantage plans?
Transitional care management codes apply to both. Some commercial payers are reimbursing for them as well, but you will need to check with those payers individually to confirm their payment policies. For more information see “Transitional Care Management Services: New Codes, New Requirements” [May/June 2013].
Transitional care and length of stay
Is there a minimum length of stay required for billing transitional care management?
No. Neither the Federal Register nor Medicare requires a minimum length of stay to report these services.
How should we code for a health coaching service?
There is no CPT code explicitly for health coaching. To the extent such coaching is focused on promoting health and preventing illness or injury, the most appropriate code is a preventive medicine, individual counseling code (99401-99404), chosen based on the time spent with the patient. If such counseling is provided as part of a preventive medicine visit reported with 99381-99397, then the counseling codes cannot be separately reported. For a diagnosis, you should use a code from the V65.4x series (Other counseling, not elsewhere classified), which includes health advice, education, and instruction.
Editor's note: Some payers may not agree with the advice given. Refer to current coding manuals and payer policies.
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