Coding Strategy

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

• 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
• Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate complexity….) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 show that the E/M and the x-rays were separate services
• 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
• 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor: Torrey Kim, CPC

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This modifier is key to E&M and counseling codes cohabiting on your claim.

Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?

Idaho Subscriber

Answer: You can, and in most cases will, report counseling codes along with E/M services. The behavior change intervention codes are intended to be reported in addition to an E/M service when the provider furnishes them. Most counseling sessions occur after the provider performs some sort of E/M. Consider this case study:

A new patient presents to the gastroenterologist reporting intense heartburn and “vomiting bile” for about a week. The patient’s skin is a splotchy yellow, and he reports experiencing generalized fatigue “for as long as I can remember.” Due to the smell of alcohol and the patient’s symptoms, the physician asks the patient if he has been drinking. The patient says “Yes,” so the physician decides to conduct the CAGE test to gauge alcohol abuse

Based on the test results, the physician determines that the patient is at least moderately dependent on alcohol; she performs extensive counseling and recommends the patient start attending Alcoholics Anonymous or some other community support group for alcohol-addicted individuals.The physician then finishes her patient exam.

She also recommends that the patient schedule a follow-up visit for a cirrhosis screening. The alcohol counseling lasted 18 minutes, and notes indicate the physician also performed a level-two E/M.

In this instance, the gastroenterologist performs both an E/M service and alcohol counseling. On the claim, you would report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decisionmaking…) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M was a separate service from the counseling;
• 787.04 (Bilious emesis) appended to 99202 to represent the vomiting;
• 787.1 (Heartburn) appended to 99202 to represent the heartburn;
• 782.4 (Jaundice, unspecified, not of newborn) appended to 99202 to represent the skin condition;
• 780.79 (Other malaise and fatigue) appended to 99202 to represent the patient’s fatigue;
• 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; 15 to 30 minutes) for the counseling service; and
• 305.00 (Alcohol abuse; unspecified) appended to 99408 to represent the patient’s alcohol dependence.

@ Gastroenterology Coding Alert. Editor: Chris Boucher, CPC

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When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.

Question: If the cardiologist performs a pacemaker insertion in the hospital and later visits the patient in observation, should I code the observation visit?

Georgia Subscriber

Answer: You should not charge this visit separately. Pacemaker insertion code 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) has a 90-day global period.

For payers applying Medicare rules, that means that payment for the pacemaker insertion service includes the following services (among others) for 90 days following the procedure:

• Services related to complications following surgery, not requiring additional trips to the operating room
• Postoperative visits (follow-up visits) related to recovery from the surgery
• Postsurgical pain management by the surgeon.

FYI: Medicare specifies certain visits that are not included in the global package, meaning you may report them separately:

• Visits unrelated to the diagnosis that prompted the surgical procedure (unless the visits occur due to complications)
• Treatment for the underlying condition or an added course of treatment which is not part of normal surgery recovery
• Diagnostic tests and procedures
• Clearly distinct surgical procedures which are not re-operations or treatment for complications
• Treatment for complications which requires a return trip to the operating room.

When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

Source: You can find the definition of the global surgical package in Medicare Claims Processing Manual, Chapter 12, Section 40.1.A.

@ Cardiology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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You have two options depending on the next step.

Question: Our vascular office performs blooddraws and analysis for a local hospital. Can we bill for a lab draw in an office setting, and if so, what codes should we use?

Georgia Subscriber

Answer: If you’re sending your patients to an outside lab for both the blood draw and testing, you cannot report any blood draw codes. If your office collects the blood, you have two coding options, depending on the next step.

Option 1: Since it sounds like your practice has its own laboratory to perform blood tests, you can report 36415 (Collection of venous blood by venipuncture) for the venipuncture, assuming that the lab has Clinical Laboratory Improvement Amendments (CLIA) certification.

Option 2: If the collected blood specimen goes to an outside lab for testing, you should report 36415 for the blood draw and add modifier 90 (Reference [outside] laboratory).

Also keep in mind that most Medicare carriers allow one collection fee for each patient encounter, regardless of the number of specimens drawn. If an E/M service is provided and billed, most payers will bundle 36415 into the E/M service.

Finally, be sure to document the blood draw. All services administered to the patient, including the blood draw, must be documented in the patient’s medical record.

@ Medical Office Billing & Collections Alert. Editor: Leesa A. Israel, CPC, CUC, CMBS

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Use these FAQs to achieve level 5.

A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.

How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report these incidents.

When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you’ll need to code correctly each time.

What Are the Caveat Basics?

“In real life, ED physicians are not always able to obtain a complete history from a patient. Of course the physician should always document any history they can obtain from the patient, family or friends, EMS, nursing home, etc.,” says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, however, the caveat “allowsthe physician to receive ’full-credit’ for even a comprehensive history – if you document why the history could not be obtained,” Lemanski stresses.

“The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required [history] information,” relays Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be due to the urgency of the patient’s condition or the physician’s mental status.

For instance: The ED physician performs a comprehensive exam and high-complexity medical decision making for a patient, but she cannot get enough information from the patient for a comprehensive history. If you invoke the ED caveat in this instance, you might be able to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).

How About a Clinical Example?

Consider this potential ED caveat scenario, courtesy of Edelberg:

A 64-year-old patient presents to the ED with altered mental status and left-sided facial droop. The physician examines the patient, but the patient cannot provide any useful history information. The physician orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes indicate that the physician performed a comprehensive exam and high MDM.

In this scenario, you might be able to invoke the ED caveat if the physician documented her inability to obtain a full history, and report 99285 for the encounter.

How Can I Spot Potential Caveat Claims?

In a perfect world, the physician would stamp “ED caveat” on each relevant claim, but coders will have to be good spotters to make the caveat work for them.

How? Coders might be able to identify caveat situations based on terms the physician uses, says Bettencourt. Some terms that could indicate a caveat if they appear in the notes include:

• history unobtainable
• history obtained by family member due to altered mental status.

Other possible keys: Lemanski offers these terms that might indicate a patient that is unable to fully communicate:

• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs.

How Do I Document the Caveat Situation?

In order to submit a successful caveat claim, however, you need to include two specific pieces of information. Find out what they are by subscribing to the ED Coding Alert.

Editor: Chris Boucher, CPC

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