CODING & DOCUMENTATION

No, it is not necessary to specify the amount of time you spent on each portion of an E/M service. That would be contrary to CPT’s intent of reducing the burdens associated with documentation and code selection. It is, however, necessary to note specifically that you did not include the time you spent on any separately reported service on the same date (e.g., “total time 20 minutes, not including the time associated with the unrelated removal of a skin lesion”). Make sure your visit documentation supports the amount of time spent by noting you reviewed prior records, patient history, or test results, for example, or by listing specific topics of counseling and discussion. Some payers may have more specific documentation requirements in their payment policies or physician manuals.

While there are preferred influenza vaccines for patients 65 and over — trivalent adjuvanted (CPT code 90653), trivalent high-dose (90662), and recombinant trivalent (90673) — Medicare covers any of the current adult influenza vaccines. (See the Medicare-covered vaccines and codes.) Report HCPCS code G0008 to Medicare for the administration of the vaccine in addition to the code for the vaccine product.

Yes, but the chief complaint may appear in any form within the documentation of the history, examination, assessment, and plan for the visit. There is no requirement to label a portion of the documentation “chief complaint.” This is especially true in a hospital setting where a patient may be seen multiple times before and after midnight for the same reason and the chief complaint is evident in the entire record of the physician’s services during the stay. The physician’s documentation should demonstrate the medical necessity of all services, of course, regardless of whether they’re related to the chief complaint.

Append modifier 33 to a code to indicate that the service, which could be diagnostic or therapeutic in other contexts, was for preventive purposes only. For example, the same laboratory code could represent preventive screening or diagnostic testing. Do not append modifier 33 to codes for services that are inherently preventive (e.g., routine health examination). The diagnosis code linked to the CPT code for the test should also indicate a screening service when you report modifier 33. Utilization of modifier 33 may vary by payer.