CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2004 Nov-Dec;11(10):35-36.
- A limit to 99214?
- When someone else discharges your hospitalized patient
- Coding a flu shot
- Coding for a delivery by the resident
- Same-day E/M & circumcision
- Coding assessment and CPR
- Observation to inpatient status
- Coding for sports event coverage
- ICD-9 code for hearing loss
- Maintenance of a PICC line
A limit to 99214?
Is there a limit to how often a physician may submit 99214? There have been times when I’ve submitted 99214 three times a month for the same patient.
CPT does not set a limit on the number of times a physician may submit 99214. Any time 99214 accurately identifies the service performed and documented, it is appropriate to use the code. That said, some payers may question the medical necessity of providing this level of service beyond a certain frequency within a certain period of time. You may need to discuss this with your payers on a case-by-case basis.
When someone else discharges your hospitalized patient
If I see my patient in the hospital one day and then a subspecialist also sees the patient, discharges her from the hospital and submits a hospital discharge code, can I also submit a hospital discharge code for the discharge work I do (e.g., dictating the discharge, calling in prescriptions and arranging follow-up)?
No, it would not be appropriate for both of you to submit a hospital discharge code. CPT states that when a physician other than the attending physician provides concurrent care services, that physician should submit the appropriate subsequent hospital care codes (9923199233) on the day of discharge. So, if you are the attending physician, you should submit the appropriate hospital discharge code (99238 or 99239) and the subspecialist should submit a subsequent hospital care code. CPT also states that the hospital discharge codes include, as appropriate, “final examination of the patient, discussion of the hospital stay even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.”
Coding a flu shot
If an established patient receives a flu shot from the nurse, what CPT code should we submit in addition to 90658, “Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use”? Should we use 90471, “Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections); one vaccine (single or combination vaccine/toxoid)” or 99211?
If the only service the patient receives is the “flu shot,” you should submit 90471 with 90658 for non-Medicare patients or G0008 with 90658 for Medicare patients. Codes 90471 and G0008 describe the administration of the vaccine.
I would not recommend using 99211 to represent the administration of influenza vaccine. If the nurse provides a medically necessary, significant, separately identifiable evaluation and management (E/M) service in addition to the flu shot, it may be appropriate to submit 99211 with modifier -25 attached in addition to 90658 and the corresponding administration code.
Coding for a delivery by the resident
Occasionally, in our teaching residency faculty group, a physician will arrive after the baby and/or placenta has been delivered. In these cases, the resident performs the delivery, but the teaching physician still provides supervision, further care and education (including managing the labor by phone before arriving and taking the liability risk in obstetrics management). Can the teaching physician bill Medicare or other payers for the vaginal delivery in this case?
In most cases, no. If you were not present for the delivery, you should not bill Medicare for it. The Medicare teaching physician rules clearly require the teaching physician to be present for the delivery. The services of residents are typically paid from other sources (e.g., Medicare graduate medical education payments to the facility). So, if you did not participate in the delivery, you can only bill Medicare for other portions of the maternity global package in which you were involved, such as antepartum and postpartum care.
Note that some state Medicaid programs and some commercial payers may have less stringent standards than Medicare and may allow the teaching physician to bill for the delivery as long as he or she was available by phone. You should check with the principal commercial payers to whom you bill your services for instructions on what services may be billed by the teaching physician.
Same-day E/M & circumcision
When E/M services are performed on the same day as a circumcision, we submit the following codes but do not receive reimbursement from the insurers: 99431, “History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records (This code should also be used for birthing room deliveries.),” V30.00, “Single liveborn, born in hospital, delivered without mention of cesarean delivery,” 54150, “Circumcision, using clamp or other device; newborn,” and V50.2, “Routine or ritual circumcision.” What are we doing wrong?
The codes you’re submitting seem appropriate since CPT does not anticipate that 99431 and 54150 should be bundled or otherwise not reported on the same date of service, but you may want to attach modifier -25 to 99431 to indicate that the E/M service was significant and separately identifiable from the circumcision done on the same date. The different diagnosis codes you submit should help support this. However, some payers’ payment policies simply do not allow payment of visits and procedures on the same date of service.
Coding assessment and CPR
One of my patients passed out and had a cardiac arrest in her car in our parking lot after a blood draw. I performed an assessment and carried out CPR until the ambulance arrived. What code(s) should I submit for this?
You should document your assessment, and code the appropriate E/M service for that assessment. If the time involved was 30 minutes or more, you may want to consider using the critical care codes (99291 and 99292). You should also submit 92950, “Cardiopulmonary resuscitation (e.g., in cardiac arrest).”
Observation to inpatient status
When the hospital retroactively changes one of my patients from “observation status” to “inpatient status,” can I then submit an initial hospital care code (99221-99223) in lieu of an initial observation code (99218-99220)?
Yes, in some cases. CPT’s initial observation codes should be used only to report encounter(s) between the supervising physician and the patient when the patient is designated as being in “observation status.” Note, however, that some payers, such as Medicare, may want you to use the code that reflects the patient’s status at the time the service was rendered, regardless of the subsequent change in status by the hospital.
Coding for sports event coverage
If I’m providing sideline coverage at an athletic event, treat a patient on the field and then provide follow-up care in the office a few days later, can I be reimbursed for the services I rendered on both days?
No, unless your arrangement with the sponsoring sports organization indicates otherwise, you should not submit codes for the services you provided at the event. As a team doctor, you are either volunteering your services on the field or receiving compensation directly from the sponsoring organization. However, for the follow-up service you provide in your office (assuming it is outside your responsibilities as team doctor), you should submit the appropriate codes just as you would for any other service provided in your office.
ICD-9 code for hearing loss
What ICD-9 code should I use for hearing loss caused by noise at work?
For the primary diagnosis, you should use a code that reflects the type of hearing loss experienced by the patient (e.g., 388.12, “Noiseinduced hearing loss” or a code in the 389 series, “Hearing loss”). For the secondary diagnosis, you should use an E code that reflects the cause of the hearing loss (e.g., E928.1, “Exposure to noise”).
Maintenance of a PICC line
If a patient has a percutaneous intravenous central catheter (PICC) line and comes in to have a stitch replaced or secured, is this considered integral enough to an office visit to be coded as such? Or, is there a separate surgical CPT code for maintenance of a PICC line?
I believe that the type of PICC line maintenance you are describing should be coded as part of the office visit. Although CPT does have a code for PICC line repair (36575, “Repair of tunneled or nontunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site”), I don’t believe it would be appropriate in your case. In the context of code 36575, CPT defines “repair” as “fixing device without replacement of either catheter or port/ pump, other than pharmacologic or mechanical correction of intracatheter or pericatheter occlusion.”
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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