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Fam Pract Manag. 2010;17(2):46-47

Cindy Hughes is the AAFP's coding and compliance specialist and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel, which includes Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Emily Hill, PA-C; Kent Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.

No shows

Can doctors legally charge for a no-show appointment, and what should the rate be based on?

In some cases, charging for no-show appointments may be permissible. Federal Medicaid policy does not permit providers to bill Medicaid or beneficiaries any fee for missing a scheduled appointment. This may be true of some managed care contracts as well. On the other hand, the Centers for Medicare & Medicaid Services allows physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they also charge non-Medicare patients for missed appointments. State law may have bearing on this answer so check with your attorney or state medical board.

A rule of thumb for setting the fee would be to cover the costs of pre-appointment work (e.g., establishing or reviewing a chart) or any actual lost business opportunity (e.g., an unfilled appointment slot). Be sure to also consider how you will provide notification of the new fee policy to every patient and what customer service training may be necessary to avoid conflict between staff and patients when the fee is charged.

Diabetic foot exams

When a Medicare patient with diabetes needs a foot exam and an order for shoes, what codes should I report? Are there separate codes and modifiers to report in addition to the evaluation and management (E/M) visit code?

Medicare does not allow for separate payment of an E/M code and a diabetic foot evaluation on the same date. Should you provide a diabetic foot exam to a patient with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation and not provide significant other E/M services on the same date, it may be beneficial to report this using the codes for the diabetic foot evaluation and treatment. It is important to understand the Medicare benefit and its limitations and know whether your patient receives care from a podiatrist or other physician who may have provided the service.

Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet once every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. Reporting of this service requires, at minimum, a patient history, a physical examination (including visual inspection of the forefoot, hindfoot and toe web spaces; evaluation of protective sensation; evaluation of foot structure and biomechanics; evaluation of vascular status and skin integrity; and evaluation and recommendation of footwear) and patient education.

HCPCS codes G0245 (initial service) and G0246 (follow-up service) should be reported. Code G0247 may be reported on the same date if the physician also performs routine foot care including local wound care, debridement of corns and calluses, and trimming and debridement of nails. The following diagnosis codes should be reported in conjunction with this benefit: 250.60, 250.61, 250.62, 250.63 and 357.2.

Medication management

What ICD-9 code should be reported for testing when ordered for medication management?

You should first list the code for a therapeutic drug monitoring encounter, V58.83. Report additional codes for any associated long-term (current) drug use, such as V58.64 for long-term (current) use of non-steroidal anti-inflammatory drugs (NSAIDs), or another code in the V58.61-V58.69 section.

More than four diagnosis codes

We code for well-child visits using the CPT codes for a pediatric preventive exam, each vaccine and vaccine administration. Our billing company says that no more than four diagnosis codes can be processed because of the limitations of the claim form. What should we do? Should we link all the CPT codes to a single ICD-9 code, such as V20.2?

Although a HIPAA-compliant electronic claim can include up to eight ICD-9 codes, it is true that some systems collect only four. Payers may allow vaccine and administration charges submitted with the V20.2 code linked as the primary diagnosis to each service line, but it's best to use the most specific code possible for the services rendered. The ICD-9 guidelines indicate that a diagnosis code from the V03-V06 series may be reported as a secondary diagnosis when inoculation is provided in conjunction with a preventive service, such as a well-child visit. The National Uniform Claims Committee advises splitting the services into two in a case like yours: “If more than four diagnoses are required to report the line services, the claim must be split and the services related to the additional diagnoses must be billed as a separate claim.”

Diagnosis code for drug-seeking behavior

What diagnosis code should be reported when the physician notes that the patient exhibited drug-seeking behavior?

Code V65.2, “Person feigning illness,” may be applicable, but this should be verified with the physician before assigning the code.

Deceased patient's chart review

After a patient of mine died in the hospital, one of his family members asked me to review his chart. Whose insurance should I bill, and what CPT code should I use? My review took 45 minutes.

First it would be important to verify that the family member requesting this review of the records is qualified as the patient's personal representative or executor with rights to the deceased patient's health information under your state's laws and HIPAA. Unless the review of records was related to a medically necessary service (e.g., determining health risk to family members), this is not likely a service that is covered by insurance, so I would recommend billing the family member and basing your charge on the total time spent – 45 minutes for the record review plus any time spent counseling the family member. If the family member requests a claim to submit to an insurance plan, you might use code 99499, “Unlisted evaluation and management service.”

Lack of voiding

What diagnosis code should I use to indicate a child refuses to use the toilet at school? The patient has no physical problems. His labs were normal.

If the primary focus of your visit was counseling the parent regarding concerns with the child's lack of voiding at school, code V65.49 for “Other specified counseling” may be an option. V65.5, “Person with feared complaint in whom no diagnosis was made,” might also apply.

Second opinions for nursing home patients

All three doctors in our group see nursing home patients. If Dr. A asks Dr. B for a second opinion for a nursing home patient, shouldn't this be coded as a subsequent nursing home visit and not as a consultation since both providers are within the same practice?

Effective Jan. 1, 2010, Medicare no longer pays for consultation services, so you should instead report a subsequent nursing home visit code representing the work of both physicians on that date.

Private payers may accept the billing of a consultation service if Dr. B has additional expertise to offer regarding management of the patient and if all the requirements for billing a consultation are met, including medical necessity of the second opinion. Where the requirements for a consultation are not met, Dr. B. should report a subsequent nursing home visit code for services to the patient because Dr. A and Dr. B are in the same group practice and specialty.

TB test site check

What CPT code should I use to report a visit for checking a tuberculosis test site?

You should use CPT code 99211 for the encounter.


Send questions and comments to, 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.

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