CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2003 Apr;10(4):26.
Occasionally, I’ll call in a hospital admission at night but won’t see the patient to do the history and examination until the next day. I know I should bill for initial hospital care, but will the fact that the date of the examination does not match the date of the admission cause claim denials?
No. The initial hospital care codes (99221–99223) represent “the first hospital inpatient encounter with the patient by the admitting physician.” This will often, but not always, coincide with the date of admission. It should not cause a claim denial when it does not coincide, because the code represents the initial encounter in the hospital with the admitting physician, regardless of whether that was on the date of admission recorded by the hospital.
New or established patient?
If a patient leaves our practice, establishes with another physician and then returns to our practice in less than three years, can we bill that patient as new rather than established?
It depends on how much time passes between the face-to-face services your practice provides to the patient. If you or another physician of the same specialty in your group has provided the patient with a face-to-face service reported with a specific CPT code in the past three years, the patient is an established patient even if he or she left the practice and established with another practice in the interim. According to CPT, a new patient is “one who has not received any professional services from the physician or another physician of the specialty who belongs to the same group practice within the past three years.” CPT defines “professional services” as “those face-to-face services rendered by a physician and reported by a specific CPT code(s).” Although CPT does not define “group” in this context, it is generally understood that physicians who share a tax identification number are part of the same group, regardless of their practice location. So if you work in a group with multiple practice locations, be aware that a patient who otherwise meets the definition of “new” is not considered new if he or she is seen at a different practice location by a physician of the same specialty.
What code should our hospital-based clinic submit for an allergy injection when we provide the antigen? What about when an outpatient pharmacy provides the antigen to us?
When your clinic provides and administers the allergenic extract (i.e., antigen), you should submit 95120 or 95125 for “professional services for allergen immunotherapy in prescribing physician’s office or institution, including provision of allergenic extract,” depending on the number of injections given. These codes describe the entire service of preparing, providing and administering the antigen at a single patient encounter. If an outpatient pharmacy provides the antigen to the patient, who brings it to your clinic for administration, you should submit 95115 or 95117 for “professional services for allergen immunotherapy not including provision of allergenic extracts,” again depending on the number of injections given. These codes reflect the administration (i.e., injection) of the antigen; they do not include the provision or preparation of it.
Note that Medicare requires you to bill only the component codes; it does not accept the complete allergy codes 95120 and 95125. If you provide the complete service (i.e., preparation and administration of the antigen) to a Medicare patient, you should submit the appropriate codes that represent the antigens and their preparation (95144–95170) in addition to the administration code (95115 or 95117).
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. Because CPT and ICD-9 codes change annually, 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.
WE WANT TO HEAR FROM YOU
Send questions and comments to firstname.lastname@example.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 © 2003 by the American Academy of Family Physicians.
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