CODING & DOCUMENTATION
Fam Pract Manag. 2014 Mar-Apr;21(2):27.
Author disclosure: no relevant financial affiliations disclosed.
Our practice would like to perform chart reviews to determine if our current documentation practices will support ICD-10 code selection. Can you recommend an approach to this project?
Look at your documentation for services provided for your practices' most common diagnoses. Start with a manageable number of conditions and charts per physician or other qualified health care professional. You can pull a report of the most commonly reported ICD-9 diagnosis codes from your billing system, or use a more generalized approach by selecting diagnoses from the top 100 codes identified on the ICD-9 Codes for Family Medicine 2011–2012: The FPM Short List.
Once you have identified the charts and diagnoses you wish to review, determine the elements of documentation necessary to support code selection in ICD-10. It may be helpful to develop tables or lists for each condition. For example, the elements of documentation for Type 2 diabetes include the following:
Type of diabetes documented as Type 2 or not specified (i.e., documentation excludes reporting of Type 1, secondary, gestational, or diabetes in pregnancy),
Status of diabetes (e.g., controlled, inadequately controlled, or with hyperglycemia),
Insulin use, if applicable,
Complications (e.g., diabetic retinopathy with or without macular edema; or diabetic ulcer location, depth, or associated gangrene),
Unrelated conditions (e.g., decubitus ulcer site and stage).
The resources that you create may later be used as guides for documentation templates or improvement initiatives.
I am billing CPT code 95004 once for each allergen tested, but what E/M code should I bill?
You should report the E/M code that reflects any work you documented that goes beyond the work associated with code 95004. In the office setting, this would typically be a code from the range 99201-99215, with modifier 25 appended to indicate that a significant, separately identifiable E/M service was performed. Please note that an E/M code should not be submitted for allergy test interpretation and report, because these are part of the 95004 service. Also, patients who have been evaluated on a previous date and return for scheduled allergy testing will often require no significant and separately identifiable E/M service on the date of testing.
Telephone call services
Can payer contracts preclude our practice from collecting direct payment from patients for phone call services?
Yes. You should review your contracts to determine what is permissible. In particular, determine how payers treat the CPT codes for telephone calls with patients (99441-99443) as part of their fee schedules. If a payer considers telephone services bundled into other services, it may not permit you to charge the patient for them. If a payer considers telephone services noncovered and, thus, the patient's responsibility, then charging the patient for them may be entirely appropriate.
For telephone or Internet consultations with other providers, new codes 99446-99449 were introduced in January 2014. For more information, see “CPT Update for 2014” [FPM, Jan/Feb 2014].
WE WANT TO HEAR FROM YOU
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 © 2014 by the American Academy of Family Physicians.
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