CODING & DOCUMENTATION
Fam Pract Manag. 2007 Sep;14(8):12-13.
- Reporting a vaccine-only visit
- Group visits and Medicare
- Applying dressing to a burn
- Shared visits as consultations?
- Polyp removal during a colonoscopy
Reporting a vaccine-only visit
How should we bill for a vaccination-only visit? Is it appropriate to report an office visit code or a preventive visit code because we take the patient's temperature and ask about allergies and general state of wellness?
It is not appropriate to report either an evaluation and management (E/M) office visit code or a preventive visit code for a vaccination-only visit. Instead, use one of the vaccine administration codes, 90465-90474. Work such as taking a patient's temperature and asking about allergies and general state of wellness before a vaccination is reflected in the vaccine administration codes. Be sure to submit codes for the vaccines as well, if appropriate.
Group visits and Medicare
I am interested in adding group medical visits to my practice. However, I cannot find anything in the Medicare Part B manuals that addresses how Medicare pays for these services. Are group visits covered by Medicare and, if so, what codes should I submit?
As you note, Medicare has not addressed group medical visits in the Part B manuals. However, earlier this year, the Centers for Medicare & Medicaid Services (CMS) responded to a request for an official answer to the question of which codes should be reported when a face-to-face E/M service is performed in the course of a shared medical appointment, the context of which is educational.
CMS' official response says that “… under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E/M service (e.g., CPT code 99213 or similar code depending on the level of complexity) to a particular patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.” CMS goes on to explain that Medicare will not pay for the observation of any services or for any subsequent group counseling or discussion of the observed services. Also, the services provided to the group should not influence the level of history, exam, counseling, instruction or medical decision making used to determine the E/M code for the individual patient service. In other words, medically necessary services provided directly to the patient during a group medical visit are reimbursable and should be reported with the office or other outpatient CPT code that reflects the level of service provided.
Applying dressing to a burn
Can I bill 16020 if I did not do the burn debridement but did apply dressing to a burn?
Yes. According to CPT, code 16020 involves “Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5 percent total body surface area).” The codes 16020-16030 include the typical pre- and post-work of minor surgical procedures but not any E/M services provided, so be sure to code the office visit in addition to the debridement code.
Shared visits as consultations?
In our hospital, many hospitalists, subspecialists and surgeons use nurse practitioners to do initial consultations, including interviewing and examining the patients, writing orders and dictating for us, the physicians. On that same day, we then talk with the patient, examine pertinent organ systems, develop an assessment and plan of care, document accordingly, and bill a level of service that takes into account the nurse practitioners' services as well as ours. Is this allowed for Medicare patients?
Medicare has explicitly prohibited billing shared visits as consultations. Chapter 12, Section 30.6.10(a) of the Medicare Claims Processing Manual states, “A consultation shall not be performed as a split/shared E/M visit.” This means that either the nonphysician practitioner can bill for the consultation service based only on the service that he or she provided, or you can bill for the consultation service based only on the service that you provided. For more information, see “A Refresher on Coding Consultations,” FPM, March 2007.
Polyp removal during a colonoscopy
If I perform a screening colonoscopy and remove a polyp during the procedure, which codes should I report?
If, during the course of the screening colonoscopy, you detect a polyp that results in a biopsy or removal, report the appropriate CPT code for a colonoscopy with biopsy or removal (e.g., 45380 for a colonoscopy with biopsy or 45384 for a colonoscopy with removal of tumor(s), polyp(s) or other lesion(s) by hot biopsy forceps or bipolar cautery). The appropriate ICD-9 code would be 211.3 for a benign neoplasm of the colon. Should the polyp be malignant, choose the appropriate code from the 153 or 154 series. These codes should be reported in addition to the screening code V76.51. Link the diagnosis code for the condition to the procedure on the claim form.
Note that the Medicare Part B deductible has been waived for screening colonoscopy, sigmoidoscopy and barium enema (as an alternative to colonoscopy or sigmoidoscopy). However, the deductible is not waived if the colorectal cancer screening becomes a diagnostic colorectal test, i.e., the service actually results in a biopsy or removal of a lesion or growth. It would be helpful to explain this to the patient prior to undergoing a screening colonoscopy to save time and prevent confusion.
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 © 2007 by the American Academy of Family Physicians.
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