CODING & DOCUMENTATION
Fam Pract Manag. 2019 Nov-Dec;26(6):30.
Author disclosure: no relevant financial affiliations disclosed.
- WORK RELATIVE VALUE UNITS
- VACCINATION REFUSAL
- MARIJUANA USE
- LESION TREATMENT FOR NEW PATIENTS
- PATIENT DISCHARGE WITHOUT SEEING PATIENT
WORK RELATIVE VALUE UNITS
Where can I find a list of current work relative value units (RVUs) for each CPT code?
You can download Excel files from the Centers for Medicare and Medicaid Services (CMS) at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. If you are seeking this information in relation to a service provided on a particular date, be sure to select the pertinent file. For example, the first file published in 2019 is listed as RVU19A, and the last file, updated in October, is labeled RVU19D. The CMS files relate to payment under the Medicare Physician Fee Schedule, but many private payers use these files to value their services as well.
What should I report when I provide a preventive medicine service with immunization counseling to a child but the parents refuse the immunization?
Report the age-appropriate preventive E/M service code (99391-99394) with the appropriate ICD-10 routine child health examination code (Z00.121 or Z00.129) as well as Z28.82, “Immunization not carried out because of caregiver refusal.” If the child is beyond the recommended age range for an immunization, you should also code Z28.3, “Underimmunization status.” When caring for an ill child who is underimmunized, assigning a diagnosis of underimmunization helps to show that a higher level of medical decision making was required.
We are seeing more patients who report marijuana use as part of their social history but who have no related complaints. Should a code be assigned for this?
No. The ICD-10 guidelines state that codes for psychoactive substance use disorders (e.g., F12.90, “Cannabis use, unspecified, uncomplicated”) should be reported only when the psychoactive substance use is associated with a physical, mental, or behavioral disorder and the relationship is documented in the physician's note for the encounter. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), patients with mild substance use disorders have two or three of 11 symptoms. Also note that the term “uncomplicated” in the ICD-10 code descriptor should not be seen as prohibiting use of the code when mild substance use is documented and meets ICD-10 reporting criteria.
LESION TREATMENT FOR NEW PATIENTS
Can I report a new patient evaluation and management (E/M) service in addition to CPT 17000, destruction of a premalignant lesion?
Yes, you may report both services if the E/M service goes beyond the typical preservice work of the destruction and the other code requirements are met. The E/M service could be for the same diagnosis or a different one. If it is for the same diagnosis, remember that CMS factors the decision to perform a minor surgical procedure into the payment for the procedure. The fact that the patient is “new” to the clinician is not sufficient justification to report an E/M service on the same date of service as a minor surgical procedure.
PATIENT DISCHARGE WITHOUT SEEING PATIENT
I approved discharge of a Medicare patient after discussing lab results with the nurse by phone but without actually seeing the patient on the date of discharge. Can I report code 99238, “Hospital discharge day management; 30 minutes”?
No. To report 99238, you must spend time on the date of discharge on the patient's unit or floor doing work related to the individual patient's discharge. Medicare and most other payers require a face-to-face encounter with the patient to report 99238 or 99239, “Hospital discharge day management; more than 30 minutes.” Although discharge day management services do not require specific examination of the patient, codes 99238-99239 are reported based on unit/floor time. The unit/floor time includes, as appropriate, final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions, and referral forms. The time spent by the physician on the date of discharge does not have to be continuous. Code 99238 is valued for 2.06 total relative value units, and 99239 is valued for 3.02 total relative value units.
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