CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2004 May;11(5):29-30.
- Documenting time
- Low-level initial hospital care
- Office visit & injection
- Emergency inpatient consultations
- Two skin lesion biopsies
- Lab prep codes
- Coding the use of Dermabond
- Splinter removal
- Coding a comparison X-ray
I recently created an office visit template that includes blanks for noting “nurse time in,” “MD time in,” and “time out” and a check box for indicating “> 50 percent of time spent counseling patient on illness, treatment options, diagnostic tests and/or follow-up instructions.” Would this documentation be sufficient in the face of an audit?
While the time-related check box you describe does alert reviewers to the fact that the encounter was coded based on time rather than on history, exam and medical decision making, the documentation is not sufficient unless you also describe what was involved in the counseling and coordination of care. The Documentation Guidelines for Evaluation and Management Services state that “if the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.”
Note that since the physician time with the patient is the only time that’s relevant, your notation of “nurse time in” is unnecessary. Noting the total time spent with the physician or mid-level provider would be sufficient. See Family Practice Management’s encounter form at https://www.aafp.org/fpm/20031000/emvisitprogressnote.pdf for an example.
Low-level initial hospital care
If the first hospital inpatient encounter with a patient by the admitting physician does not meet the requirements of a 99221 (e.g., because the majority of the work-up was already done in the office the day before), how should that hospital encounter be coded?
You should check with the payer to be sure. Medicare and CPT offer different advice. When the office visit qualifies for a level-V office visit or consultation code, Medicare advises physicians to report the lowest level initial hospital care code (99221) for the hospital encounter, even if the initial hospital care history and physical is less than comprehensive. CPT gives slightly different advice, saying that if a service does not meet the components required for even the lowest level of initial hospital care, it should probably be coded with the appropriate subsequent hospital care code instead.
Office visit & injection
If I determine that a patient needs an injection during an office visit, can I submit codes for the E/M office visit, the injection administration and the injectable?
Yes. In the notes preceding the immunization administration codes (90471-90474), CPT states that “if a significant, separately identifiable evaluation and management [E/M] service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.” The same principle would apply to the therapeutic/prophylactic/ diagnostic injection codes (90782-90799). Keep in mind that this assumes the E/M visit is significant and separately identifiable from the injection. If the patient simply presents for the injection service and no evaluation and management of the patient is done, an E/M visit code should not be coded in addition to the injection administration and medication codes.
Some payers do not follow CPT’s guidelines on this point. For example, Medicare will not separately pay for 90782 when it’s billed in conjunction with an E/M service. Check with the payers you contract with to determine their individual requirements.
Emergency inpatient consultations
Are there special codes or modifiers for in-hospital consultations performed under emergency circumstances in the middle of the night or on weekends?
No. CPT’s inpatient consultation codes (99251-99255 for initial inpatient consultations and 99261-99263 for follow-up inpatient consultations) do not specify the circumstances under which the inpatient consultation is provided, and there are no modifiers or other special codes that do this either. Though there are special services codes that describe services requested between 10 p.m. and 8 a.m. (99052) and services requested on Sundays and holidays (99054), I would not recommend using them in the situation you describe because they were intended for office-based practices whose usual posted hours do not include this time frame.
Keep in mind that it may be appropriate to bill for critical care if the condition of the patient meets the criteria in CPT.
Two skin lesion biopsies
How should I code two skin lesion biopsies done at the same encounter?
You should submit code 11100, “Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion,” for the first biopsy and 11101, “Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (list separately in addition to code for primary procedure),” for the second biopsy.
Lab prep codes
What codes should I submit for the following two scenarios: (1) I scrape skin and prepare a KOH prep to look for infectious agents, and (2) I perform a vaginal examination and make two slides of vaginal contents (one with saline and one with KOH) to look for infectious agents?
In the first scenario, the appropriate CPT code would be 87220, “Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies).” For Medicare patients, the appropriate HCPCS code would be Q0112, “All potassium hydroxide (KOH) preparations.”
In the second scenario, the appropriate CPT code would be 87210, “Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)”; and because you have two smears, you would need to report 87210 twice or put “2” in the units-of-service space on the claim form. For Medicare patients, the appropriate HCPCS code would be Q0111, “Wet mounts, including preparations of vaginal, cervical or skin specimens,” for the slide with saline and Q0112 for the slide with KOH. Note that if you were to put a single smear on one slide with saline on one half and KOH on the other, which is often how this is done, the CPT coding would be unaffected (except that you would code this with one unit of service instead of two). However, the Medicare coding would be more problematic in this case. Reporting both codes could imply that you did two slides instead of one, which would be a misrepresentation of your work. Reporting only one of the two codes is probably the more reasonable option.
Coding the use of Dermabond
Is there a CPT code specifically for using Dermabond rather than sutures or staples for wound closure?
No. CPT’s repair codes (12001-13160) are used to designate wound closure using “sutures, staples or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips.” Thus, according to CPT, tissue adhesives such as Dermabond are part of the supplies usually included with the repair codes and are not separately reportable. Note that for Medicare, however, if only tissue adhesive is used, you should submit G0168 for “Wound closure utilizing tissue adhesive(s) only.”
What is the CPT code for removal of a 1.5-cm splinter from below the dermis of the foot, when local anesthesia is required for exploration and enlargement of the wound to reach the object with forceps?
Since the splinter was subcutaneous, the most appropriate CPT code to submit for the procedure you describe is 28190 “Removal of foreign body, foot; subcutaneous.” Use of local anesthesia is included in this code and cannot be reported separately.
Coding a comparison X-ray
If I request an X-ray of a patient’s symptomatic ankle and an X-ray of the other ankle for comparison purposes, how should I code the comparison X-ray? Should I attach modifier -50, “Bilateral procedure” to the appropriate code from the radiology section of CPT?
The use of modifier -50 is not generally recommended for reporting bilateral radiology exams. Instead, the appropriate radiology code should be listed twice on the claim form. That said, some payers may require you to attach HCPCS modifiers -RT and -LT to the respective codes. Other payers may just require you to report the appropriate code once with a “2” in the units-of-service field on the claim form.
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.
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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 © 2004 by the American Academy of Family Physicians.
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