Coding Strategy

Study frequency guidelines before you bill for counseling services.

Question: A 60-year-old established Medicare patient with a confirmed diagnosis of vanishing lung (emphysema) reports to the family physician (FP) for a medication check and blood work; the patient is a moderate smoker. During the medication check and blood work, which took about 5 minutes, the patient tells the practice’s non-physician practitioner (NPP) “I think I’m ready to quit smoking; can you help?” The NPP spends the next 7 minutes providing smoking cessation counseling for the patient. Can I report a cessation code and an E/M?

Answer: Provided the patient meets Medicare’s requirements for cessation counseling, you can report the following:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes or less are spent performing or supervising these services.) for the E/M

• 492.0 (Emphysema; emphysematous bleb) appended to

• 99211 to represent the patient’s emphysema

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for the smoking cessation counseling

• 305.1 (Tobacco use disorder) appended to 99406 to represent the patient’s tobacco dependency.

Know the rules: According to Medicare, its patients are entitled to smoking and tobacco use cessation counseling provided the patient is either:

• a tobacco user who has an illness caused or complicated by tobacco use or

• taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information.

Additionally, note these two frequency guidelines for spot-on 99406 and 99407 (… intensive, greater than 10 minutes) claims:

• Medicare will cover up to two counseling attempts per year for the first 12-month period of counseling (Each attempt can include up to four counseling sessions).

• Medicare will cover up to eight more sessions during a second or subsequent 12-month period of counseling after 11 full months have passed since the first Medicare covered cessation counseling session was performed. For example, if the first of eight covered sessions was performed in April 2009, a second series of eight sessions may begin in April 2010.

@ Family Practice Coding Alert (Editor: Chris Boucher, CPC).

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Don’t assume 90911 is the correct code choice.

Question: Is there a procedure code for billing for Kegel exercise teaching? Can we use code 90911 or possibly 97110?

Answer: There are no specific CPT or HCPCS codes for the performance of or teaching of Kegel exercises. To bill for teaching a patient how to properly perform these exercises, a nurse or medical technician must document a brief history and physical examination as well as the indications for and the expected goals of the Kegel exercises. Under these circumstances, you can then report 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician …) for this encounter.

About the service: Kegel exercises are voluntary contraction and relaxation of the perineal musculature including the urinary sphincter (pelvic diaphragm). These exercises are usually performed outside of the office without medical staff supervision, and are a non-invasive and non-surgical treatment for female and occasionally male stress urinary incontinence.

Pitfall: You should only use 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) for the teaching of biofeedback therapy with face-to-face supervision in office by a trained member of your medical staff.

Additionally, you should use 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) only for pelvic floor muscle rehabilitation (PFMR) performed under one-on-one supervision with a physician, physiotherapist, or ancillary office staff member specifically trained in an accredited physiotherapy program.

@ Urology Coding Alert (Editor: Leesa A. Israel, CPC, CUC, CMBS).

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Test your 2010 consultation coding understanding with these questions and answers.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by taking this three-question quiz and then checking your answers against the experts’.

Question 1: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Question 2: What modifier do admitting physicians need to use in 2010 when they report an initial hospital care code (99221-99223)?

Question 3: When Medicare is the patient’s secondary insurance and his primary insurance accepts the consultation codes, should you use a consultation code for the Medicare Secondary Payer (MSP) as well?

Answer 1: Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221- 99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the “Not Otherwise Classified” (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

Answer 2: Stick With 2 Letters for Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you’re billing for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code.

This will denote the admitting physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in an orthopedic surgeon to perform a consult for multiple fractures in the patient’s leg. The trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The orthopedic surgeon then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. “Some people are interpreting the new modifier as a ‘one,’” Cobuzzi says. “But it’s two letters, A and I,” she reminds coders. Think: A-eye.

Answer 3: Skip 99241-99255 for Medicare, Even as Secondary

Don’t even think about billing a consult to Medicare — even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultations codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare. The MSP “will not pay for consults,” says Samantha Daily, a medical biller for a practice in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes” you should bill for secondary payment from Medicare in one of the following two ways:

Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or Bill the primary payer using a consult code, and then report the amount paid by the primary payer, and change the code to the non-consult E/M code (that is equal to the consultation code/service documented and paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department.

You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.

@ Medical Office Billing & Collections Alert

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Test your ob record skills with this four part challenge.

If your ob-gyn simply confirms a patient’s pregnancy during an office visit, you’ll be able to report V72.42 (Pregnancy, confirmed). But when should you start the ob record? Take this four-part ob record challenge to discover where you stand.

Scenario 1: The ob-gyn sees a patient who knows that she’s pregnant via a positive home pregnancy test and simply “confirms the confirmation.” When should you start the ob record?

Answer: At the next visit.

If the ob-gyn performed only the urine pregnancy test, you’d report 81025 (Urine pregnancy test, by visual color comparison methods) or possibly a low-level E/M service if some discussion about her health took place.

Report V72.42 (Pregnancy examination or test, positive result). You will use this code when your ob-gyn simply tests to see if the patient is pregnant. This code will go on both the E/M code and the urine test, because you’ll be coding for what you know at the end of the visit. You won’t need any other V codes.

Scenario 2: A patient comes in for an annual exam and the ob-gyn diagnoses pregnancy. When should you start the ob record?

Answer: At the next visit.

If you began the ob record during the annual exam visit, most carriers will consider the annual exam part of the global ob service. You cannot bill the global service until delivery, but you should inform the insurance company of the pregnancy.

Remember to code any complaints, such as malaise, general fatigue, spotting, nausea, vomiting, pelvic pain, etc., that the patient presents with. You can report 99384-99386 for new patient or 99394-99396 for established patients.

Rule of Thumb: Until you know that the patient wants her pregnancy to continue, you shouldn’t initiate the global care.

Scenario 3: A patient sees your ob-gyn after her family physician discovered that she’s pregnant and wants to have her ob care with your practice. She has been seen by your practice within the last 12 months. When would you start the ob record?

Answer: During this visit.

Because another physician made the diagnosis, your ob-gyn probably wouldn’t need to “confirm the confirmation.” Therefore, he would begin the ob record, which means this service is part of the global ob package.

Tip: Some practices confirm intrauterine viability before they begin the barrage of ob coordination.

What’s involved: The ob coordination is lengthy, usually lasting about 30 minutes, and involves going over procedure guidelines, including a timetable of when to do lab tests, pelvic exams, amniocenteses, etc. The ob-gyn will usually provide vitamins and iron supplements and discuss when to call him.

Scenario 4: Your practice scheduled an initial ob appointment for a pregnant patient (who confirmed her pregnancy at home), but she can’t wait to have some of her questions answered. She wants to come in earlier for counseling. The ob-gyn would perform no initial visit or ob panel blood work during this visit. When should you start the ob record?

Answer: This scenario could go either way.

Normally, carriers consider all counseling related to a pregnancy included in the global ob service. If the patient had significant health reasons to warrant counseling, you would wrap this visit into the global care of the patient.

However, if you want to report this separately, you’d report an E/M code such as 99201-99205 for a new patient, based on the time the ob-gyn spent with her. The ob-gyn must document the duration of the counseling visit. The ob-gyn might ask, ”Does the patient intend to keep her pregnancy? Are there extenuating circumstances about high-risk situations, such as drug abuse, need for genetic counseling, or current high-risk medications?”

If the patient is established, you’d report an established patient E/M visit (99211-99215). If a nurse who was not a certified nurse midwife or a nurse practitioner saw the patient, you must use 99211 for the encounter.

As for a diagnosis code, you might try V65.40 (Counseling NOS) or V65.49 (Other specified counseling), but carriers don’t usually allow you to use these codes as the primary diagnosis. Also, if the ob-gyn discusses genetics with the patient, you can use V26.3 (Genetic counseling and testing) instead.

@ Ob-gyn Coding Alert

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Insurers might want to see a clear explanation as to why the E/M was necessary.

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the gastroenterologist started her on Nexium (esomeprazole). One of the practice’s nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced any nausea, diarrhea, vomiting, or any other side effects since she started Nexium. The patient reports that she’s “thrown up three or four times” since starting the medication, but reports no other side effects. The patient’s record indicates that the gastroenterologist scheduled this visit specifically to check how the patient’s adjustment was going. What can I report for this encounter?

Answer: It will depend on the encounter specifics, but this sounds like a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services …) service.

No matter what E/M code you choose, append the following diagnosis codes:

• 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient’s GERD
• 787.03 (Vomiting alone) to represent the patient’s vomiting

Explanation: The gastroenterologist will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though they can theoretically be higher-level if complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following documentation on medication checkup E/Ms:

• a record of patient’s blood pressure, if relevant, and other vital signs
• a note indicating the clinical reason for checking blood pressure or other vital signs
• a list of the patient’s current medications (include level of patient compliance, if possible)
• proof that the gastroenterologist evaluated the clinical information the NPP obtained and made a  management recommendation for the patient.

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