COVERING FOR OTHER PHYSICIANS
I am a solo physician who has an arrangement with physicians in another practice to provide coverage for each other's patients. When I cover for one of them and provide care to their patient for the first time, can I report a new patient service?
No, you cannot report a new patient service if the patient is established within the practice you're covering for. Per CPT, when a physician or other qualified health care professional (QHP) covers for another, the patients are considered either new or established based on their relationship to the physician for whom coverage is provided.
PREVENTIVE VISIT FOR PATIENT WHO HAS ALREADY HAD A WELL-WOMAN EXAM
Our physicians occasionally provide a preventive medicine visit to a woman who has already received a well-woman examination from a gynecologist, and our claim for service is denied. How can we resolve this?
This shouldn't occur because the taxonomy numbers of the physicians providing the two services should alert the payer to the different focus of each service. But since it is happening, an appeal may be your best approach to the denials. Some payers routinely deny the second preventive service within a year but reverse the denial when it's appealed. An appeal is an unfortunate administrative burden, but worthwhile given the value of preventive care.
BLOOD PRESSURE AND BLOOD SUGAR AS MDM DATA
Can I count a patient's blood pressure or blood sugar log as a test result reviewed when determining the level of medical decision making for an office E/M service?
Yes. This is a review of external data, and it counts toward the amount and/or complexity of data you reviewed and analyzed at an encounter.
CERTIFICATION OF ORDERS BY NURSE PRACTITIONERS
Is it correct that nurse practitioners and other non-physician QHPs can certify or recertify orders for home health services?
Yes. Physician assistants, nurse practitioners, and clinical nurse specialists may certify or recertify patients for eligibility, order home health services, and establish and review the care plan, provided these activities are within their scope of practice as outlined by their state's regulations.Report these services with codes G0179 (recertification for Medicare-covered home health services) and G0180 (certification for Medicare-covered home health services). The patient must have had a face-to-face encounter with the physician or other QHP no more than 90 days prior to the start of home health care or 30 days after the start of home health care, and that encounter must be related to the primary reason the patient requires home health services.
DIABETES AND HYPERTENSION TOGETHER
When I report diabetes and hypertension in the same patient, my coders ask if they can report an ICD-10 code for diabetes with cardiovascular complication based on guidance from an auditor looking for hierarchical condition category codes. Should my coders always assign hypertension as a complication of diabetes?
No. Unless your clinical impression is that the patient's hypertension is due to diabetes, a causal relationship is not assumed in ICD-10-CM. The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. Coders are instructed to query the physician if it is unclear whether two conditions are related. However, if your documentation includes terms linking the two conditions such as “diabetes type 2 with hypertension,” they may interpret that the patient's hypertension is associated with or due to diabetes, in which case coding guidelines would support reporting hypertension as a complication of diabetes.
