Coding & Documentation


Fam Pract Manag. 1998 Oct;5(9):13-14.

Complying with prepayment requests for E/M documentation


What will happen if my practice doesn't comply with our carrier's request for documentation as part of HCFA's random prepayment review of E/M claims?


Your claim for payment will be denied. Statistics from HCFA Region VII, which includes Medicare carriers in Nebraska, Iowa, Kansas and Missouri, show that in some months, as many as 50 percent of the claims denied by individual carriers under prepayment review have been denied due to physicians' failure to submit any documentation. Other points to keep in mind:

  • Carriers are continuing to review claims using both the 1994 and the 1997 versions of the documentation guidelines, “whichever is most advantageous to the physician,” according to HCFA's directive.

  • The prepayment reviews are not limited to E/M office visit codes. Documentation for hospital E/M claims and others may also be requested.

Documentation checklists


Is a completed template or a computerized form including check boxes considered acceptable documentation for an E/M service?


Yes, provided you elaborate on all positive and pertinent negative findings.

Referrals from chiropractors


Can I bill a consult code when the patient I saw was referred by a chiropractor?


CPT says a consultation is “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source” (emphasis added). CPT guidelines do not restrict whom may be considered an “other appropriate source,” so it is acceptable to bill a consult code based on a referral from a chiropractor.

Scope of prolonged services codes


Is it appropriate to use the prolonged services codes (99354–99357) with non-E/M codes?


According to CPT, prolonged services codes may be “reported in addition to other physician service, including evaluation and management services at any level.” This language suggests they may be used with non-E/M codes too.

Fracture care in a nursing home


If I provide closed treatment of a pelvic fracture suffered by a nursing home patient, should I use fracture care codes or subsequent nursing facility care codes?


The closed treatment of a pelvic fracture suffered by a nursing home patient should be coded using the appropriate surgical code, either 27193 or 27194. The surgery guidelines in CPT indicate that “normal, uncomplicated follow-up care” is included in the reimbursement for these codes and may not be separately billed. However, like other surgical codes, the codes for closed treatment of a pelvic fracture have been assigned a global period beyond which follow-up care, even that related to the surgical procedure, may be separately reported. That global period, according to the Medicare fee schedule, is 90 days. If during the 90-day global period you provide a subsequent nursing facility visit that is unrelated to the fracture care, you may code and bill for it separately, using the appropriate nursing facility visit code and modifier -24, which indicates that the service you're providing during the postoperative period is unrelated to the fracture care.

Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.

Leigh Ann Henry is an associate editor of Family Practice Management.

Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. For more detailed information refer to the current CPT manual and the “Documentation Guidelines for Evaluation and Management Services.”


Copyright © 1998 by the American Academy of Family Physicians.
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