TIME-BASED E/M CODING WITH SCRIBE
If I use a scribe to complete my documentation, can I include the scribe’s time when I select an E/M code for the visit?
No. For E/M code selection, total time only includes time the physician or other qualified health care professional personally spent on the visit on the date of the encounter. However, you may include time you personally spent reviewing, editing, or approving the scribe’s documentation.
DIABETIC ULCER FOLLOWING TRAUMATIC INJURY
What is the appropriate diagnosis coding for a diabetic ulcer that evolved from a traumatic injury to the patient’s left calf?
Report ICD-10 codes for the diabetic ulcer first, indicating the current reason for the encounter, and then report a code for the sequela of the injury. For a type 2 diabetic ulcer, the appropriate codes are E11.622 (“Type 2 diabetes mellitus with other skin ulcer”) and L97.22 (“Non-pressure chronic ulcer of left calf”). The code for the sequela of the injury will include a seventh character of “S” (e.g., S81.812S, “Laceration without foreign body, left lower leg, sequela”).
PROLONGED SERVICES IN ASSISTED LIVING
How do I report prolonged E/M services provided in an assisted living facility?
It depends on the payer, but in any case you must first document your total time. If your total time is at least 15 minutes beyond the required total time for the highest-level E/M code (either 99345 for a new patient or 99350 for an established patient), you may report prolonged services.
If the patient’s health plan pays for CPT code 99417 (prolonged outpatient E/M, each 15 minutes of total time on the date of the encounter), report that code in addition to either 99345 or 99350 when the total time is at least 90 minutes for a new patient or 75 minutes for an established patient. Report additional units of 99417 for each additional 15 minutes.
However, for patients with Medicare or plans that have adopted Medicare policy, you would instead use code G0318 (prolonged home or residence E/M, each 15 minutes of total time) in addition to either 99345 or 99350 when the total time (including both face-to-face and non-face-to-face time spent within three days before the visit to seven days after) is at least 140 minutes for a new patient or 110 minutes for an established patient. Note that the 11-day period allowed for G0318 is a significant difference from 99417, which you may only report for prolonged time spent on the same date as the visit itself. You must document in the medical record the time you spent on the care of that specific patient on each date during the 11-day period. As with 99417, report additional units of G0318 for each additional 15 minutes (e.g., 99345 plus G0318 x 2 units for a new patient visit with at least 155 minutes of total time).
TCM RELATED SERVICES
I provided transitional care management (TCM) services to a patient discharged from the emergency department (ED). The payer denied the claim for lack of a related service. What related service is required?
The required related service would be an inpatient or observation hospital stay or a skilled or non-skilled nursing facility stay (i.e., the payer must receive a claim from a hospital or facility for the stay before it will approve your claim for TCM). Per CPT, clinicians can provide TCM to a patient during transitions from those settings to the patient’s community setting (e.g., home, rest home, or assisted living). A discharge from the ED would not qualify the patient to receive TCM services. The patient must be discharged from one of the other settings described above.
