CODING & DOCUMENTATION
Fam Pract Manag. 2005 Nov-Dec;12(10):24.
- Coding an initial consultation
- “Worried well” exam
- Sports physicals for students
- Billing for care plan oversight
Coding an initial consultation
What code should I use for an initial office consultation that takes about 1.5 hours?
Choose the appropriate office or other outpatient consultation code based on the key components (history, exam and decision making) or based on time if counseling/coordination of care dominated the encounter. For instance, if your documentation of the 1.5 hours meets the criteria for a 99244, which typically includes 60 minutes of face-to-face time with the patient or family as well as a comprehensive history, comprehensive examination and medical decision making of moderate complexity, you can code the additional time using prolonged services code 99354. If your documentation meets the criteria for 99245, which typically includes 80 minutes of face-to-face time, you would not use an additional code because prolonged services of less than 30 minutes may not be billed separately. CPT does allow for use of modifier -21 to report prolonged services beyond that described in the highest-level code within a given category, so you could bill 99245 with modifier -21. You may want to ask your insurers whether they reimburse for the prolonged services codes or modifier -21. Unfortunately, many don’t.
“Worried well” exam
How should I code a visit by a concerned mother for her infant when the exam turns out to be normal?
You would use one of the usual office visit codes (i.e., 99212-99215, assuming the patient is established). The level of service would depend on the history, exam and medical decision making involved or the time involved, if counseling dominated the encounter. You should choose a diagnosis code (or codes) based on the signs or symptoms that prompted the mother’s concerns, or you could use the V code for “worried well,” V65.5, “Person with feared complaint in whom no diagnosis was made.” Even though you don’t identify a problem, you can still submit an office visit code because the encounter was prompted by perceived concerns (i.e., it was not preventive) and the work of a problem-oriented visit was done.
Sports physicals for students
What is the appropriate CPT code for sports physicals for high school students?
If the physical involves a comprehensive history and exam, use the age-appropriate preventive services code. Otherwise, use the appropriate office visit code.
Billing for care plan oversight
We do lots of care plan oversight but have never billed for it. Are the G0180 and G0182 codes for a 30-day period?
G0182, which is for care plan oversight of a patient under Medicare-approved hospice, is for services “within a calendar month.” The same is true for code G0181, which is for care plan oversight of a patient receiving Medicare-covered home health services. Code G0180 is for physician certification of Medicare-covered home health services. It is typically reported for a single date of service on which the physician certifies the patient’s home health services, rather than spanning a range of dates like the care plan oversight codes. For more information about care plan oversight, see “How to Document and Bill Care Plan Oversight,” FPM, May 2005.
Editor’s note: While this department attempts to provide accurate advice, payers may not accept the coding and documentation recommended. Refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for detailed information.
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Send questions and comments to email@example.com, 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 © 2005 by the American Academy of Family Physicians.
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