CODING & DOCUMENTATION
Fam Pract Manag. 2008 Nov-Dec;15(9):37-38.
- Coding blood-pressure checks
- Developmental milestones
- Instructions on use of crutches
- Medicare and lab test coverage
- Time requirements
- Wound care
- Office visit or emergency service?
- 99058 for in-office emergency
- PQRI reporting
- Mental health status assessment
Coding blood-pressure checks
What code should we use to bill for a blood-pressure check?
If the visit was scheduled at the request of the physician, you can report 99211. If the visit was prompted by the patient, you can code 99211 if there are clinical indications for the visit. For example, if in the process of having his or her blood pressure checked the patient reported dizziness and a headache, prompting the nurse to take additional history and talk with the physician, it would be appropriate to code 99211.
An encounter with a stable patient who decided to come in for a blood-pressure check simply because he or she happened to be in the neighborhood would not ualify as a level-I visit because the physician did not order the service and there were no clinical indications to warrant it.
Is it appropriate to separately bill 96110 for asking about developmental milestones during a well-child exam, or is this included in the payment for a well-child visit?
CPT code 96110 may be reported separately in addition to a preventive medicine service only when a structured developmental testing tool (e.g., Ages and Stages or the Parent Evaluation of Developmental Status) is used to assess the patient's development. Modifier 25 should be appended to the preventive medicine service code to indicate that the work involved in providing the preventive medicine service was significant and separately identifiable from that of the developmental testing. Not all payers will separately reimburse this service on the same date as a preventive service visit.
Instructions on use of crutches
We are a family medicine/urgent care facility and see patients with fractures. Can 97116 be used when we give instructions on the use of crutches?
Code 97116 is used to report gait training therapy. Some insurers pay for this code only when it is used by physicians or physical therapists or when a minimum time of service is met (e.g., at least 8 minutes). Check with your payers to learn their individual policies. If the patient is a Medicare beneficiary, make sure that you are meeting the requirements outlined in Chapter 15, Section 220.2 of the Medicare Benefit Policy Manual.
Medicare and lab test coverage
Is there a way to find out what diagnosis codes Medicare covers for lab tests?
If a National Coverage Decision (NCD) has been made by Medicare for a laboratory test, the NCD Coding Policy Manual is a good source for information – not only on covered diagnosis codes but also on frequency of coverage. The latest version of the manual is published on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov/coveragegeninfo/04_labncds.asp.
If our documentation for an office visit meets the criteria for 99214 but we spend less time with the patient than Medicare's guidelines associate with the service, do we have to drop the coding down a level?
No. If you code based on key components, you do not have to meet the average times noted in CPT. Noting the time of service can be helpful because, if counseling and coordination of care end up dominating the face-to-face time spent with the patient, you might choose to code the visit based on time (see “Time Is on Your Side: Coding on the Basis of Time”).
After I perform a complicated incision and drainage procedure, the patient often has to come back for wound repacking, cleansing and dressing changes up to five times. I am not sure I am billing correctly because the amount paid does not cover all expenses. Can you help?
The global period assigned to code 10061, “Incision and drainage of an abscess; complicated,” is 10 days. Postoperative care such as repacking and dressing changes is not separately reportable within that 10-day period. If postoperative care is necessary after 10 days, those services should be separately reported, with no modifier required.
If the care provided significantly exceeds the typical service, it is possible to add modifier 22 to the surgical code, provide information on the extenuating circumstances and increase the billed amount by a percentage that you feel is equal to the increased work and expense. Your payer won't necessarily provide the additional payment, but it might be worth a try. Note that if the procedure has already been billed, you may need to submit a corrected claim for this purpose.
Office visit or emergency service?
We often see our OB patients as unscheduled outpatients in the hospital's labor and delivery triage room after hours for non-OB concerns. Should we bill these visits as office visits (99212–99215) even though our office is an outpatient department of the hospital? Or should we bill them as emergency services (99281–99285), as this triage area is open and staffed 24 hours a day?
Though the triage room is open and staffed 24 hours a day, this does not make it an emergency department. It is an outpatient setting for which codes 99212–99215 could appropriately be used to report services. Place of service code 22, “outpatient hospital,” should be reported as well.
99058 for in-office emergency
We had a patient come in for a routine diabetic checkup, which we billed using CPT code 99213 and ICD-9 code 250.02. A few hours later, this patient came in with a migraine and hypertension issues. Could we have reported code 99058 for the second visit?
Code 99058 is to be reported in addition to the code for an emergency service provided in the office that disrupts other scheduled office services. If the migraine required such immediate attention that the physician interrupted the care of scheduled patients to provide care to this patient, reporting code 99058 may be appropriate. Many payers including Medicare do not pay separately for code 99058, so you may wish to check payer policy before adding this code to what would already be an unusual claim for two unrelated E/M services on the same date.
I received an explanation of benefits from Medicare that denies charges for the Physician Quality Reporting Initiative. The remittance advice code is N365. Does this mean that I did not successfully report for PQRI?
It sounds as though you're on track. According to CMS, the remittance advice associated with a claim containing a PQRI quality code line item will include N365 as a standard remark code and this message: “This procedure code is not payable. It is for reporting/information purposes only.” This remittance advice will confirm that the quality-data code has been captured by CMS for PQRI analysis.
Mental health status assessment
How should I code a Mini Mental Status Exam (MMSE) performed as part of an office visit with a patient who is having memory problems?
The physician administration, interpretation and written report associated with the MMSE is included in the E/M code for the patient encounter and cannot be billed separately. The 1997 version of Medicare's Documentation Guidelines for Evaluation and Management Services indicates that “brief assessment of mental status including: orientation to time, place and person; recent and remote memory; mood and affect (e.g., depression, anxiety, agitation)” is one of the exam elements for a general multisystem exam.
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 © 2008 by the American Academy of Family Physicians.
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