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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Acute episodes, check-ups are both routine for these patients.

When migraine headache coding comes up, ICD-9 codes typically dominate the conversation.

But what about the procedure codes those complicated migraine diagnoses are attached to? There are several common situations in which a migraine patient might report to the family physician (FP). Check out the top three migraine treatment scenarios, along with expert coding advice on each situation.

Situation 1: Separate E/M and Acute Migraine Tx

One of your FP’s patients might report to the practice with symptoms, and then end up requiring treatment for an acute migraine headache. Consider this example ……  from Mari Wink RHIT, CPC, ACS-EM, an independent coding consultant in New York.

Example: An established patient reports to the FP with complaints of recurring headaches. The patient’s past medical history indicates that the FP has prescribed several pain medications to combat the headaches, with no success, during previous E/Ms. The patient has, as the FP instructed her during their last encounter, kept a “headache diary” for three months.

During a level-three E/M service, the FP diagnoses “migraine headache w/o aura, HTN.” The physician then injects 10 mg of Imitrex via subcutaneous injection, writes a prescription, and sends the patient home.

On the claim, you’d report the following:

• 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the injection J3030 (Injection, sumatriptan succinate, 6 mg [code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered]) x 2 for the Imitrex supply
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expandedproblem focused history; an expanded problem focused examination; medical decision making of low 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 99213 to show that the E/M and injection were separate services 346.10 (Migraine without aura; without mention of intractable migraine without mention of status migrainosus) appended to 99213, 96372 and J3030 to represent the patient’s migraine
• 401.X (Essential hypertension) appended to 99213 as a secondary diagnosis, reflecting a comorbid condition.

Documentation alert: In order to prove medical necessity for the Imitrex injection, the notes should include proof that the FP did try alternate methods of treatmentbefore performing the injection. “It should read something like: ‘Patient has not responded well to past medication regimes as documented in previous office visits. Today we are going to inject Imitrex,’” recommends Wink.

Situation 2: Capture Care Plan Work in E/M Choice

After your FP diagnoses a patient with migraines, he often begins a plan of care to help the patient better manage her migraines, confirms Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of Denver’s MJH Consulting.

According to Hammer, a patient with a migraine diagnosis might report to the FP for:

• diagnosis management of his migraine
• medication management, including writing new or refilling current prescriptions
• evaluation of efficacy of plan of care including abortive management
• assessment of side effects associated with current treatment plan.

When the physician or nonphysician practitioner (NPP) treats migraine patients for any of the above reasons, code the appropriate E/M code or other CPT code[s].

Example: An established patient with a plan of care in place for her classic migraines reports to the FP for medication management. An NPP asks the patient how she is reacting to the medication, and if there have been any side effects. The patient reports that everything is “going fine so far.” Notes indicate a level-two E/M service.

For this condition-management E/M, you’d report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) with 346.00 (Migraine with aura; without mention of intractable migraine without mention of status migrainosus) appended to represent the patient’s migraines.

Situation 3: ID Injections in Migraine Intervention

A patient with a plan of care in place might also have an acute migraine that requires FP intervention. When this occurs, you’ll report an E/M or injection - or both, depending on the situation. Consider this example from Hammer:

Example: An established female patient with a history of menstrual migraines presents having an acute menstrual migraine with new onset of neurological symptoms. After attempting to stop the migraine with oral pain medication, the FP injects the patient with 6 mg of Imitrex and 1 unit of Compazine. Notes indicate a level-four E/M service.

To find out what you should report on this claim, subscribe to the Family Practice Coding Alert. Editor: Chris Boucher, CPC

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Medicare won’t pay 69210 alone, so here’s how to unlock payment.

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate procedure], one or both ears) to be a minor procedure. But unlike with other minor procedures, they only pay for an E/M service as well as the removal of the impacted cerumen when you have two unrelated diagnoses — one for the E/M service and 380.4 (Impacted cerumen) for the removal of impacted cerumen.

The solution: By learning just three simple steps, you can ensure your physician is getting the reimbursement he deserves for this common procedure.

Step 1: Look for Second Diagnosis

A patient does not usually present for impacted cerumen alone. Another condition, such as ear pain or hearing loss, will usually prompt the visit. When your physician documents that additional diagnosis, you can report two codes to represent the work for both services, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, 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.

First, you would report one code for the significantly separately identifiable E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient …). Then, you could report 69210 for the impacted cerumen removal. Documentation must support the medical necessity basedon symptoms and diagnosis; otherwise, the insurer will bundle the E/M service into 69210.

Note: CMS has a list of conditions for allowing you to separately bill an E/M code and 69210. They will allow separate billing when all of the following are met: The nature of the E/M is for anything other than cerumen removal.

During an unrelated encounter, the physician observes impacted cerumen or the patient complains about his ears Otoscopic examination of the tympanic membrane TM is not possible due to impaction

Removal of the impaction requires the expertise of the physician and is personally performed by him The procedure requires a significant amount of time and is clearly documented as such.

Crucial point: “Removal of impacted cerumen is not an ear wash; it takes instruments and the skills of the physician,” Cobuzzi says.

Step 2: Append Modifier 25

To receive separate reimbursement for the E/M service — and to code properly — you will need a modifier.Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code.

Tip: Always provide separate documentation for the impacted cerumen removal procedure “so that you are demonstrating that the E/M is a separate procedure from the removal of the impacted cerumen,” Cobuzzi says. Do not bury your procedure note in the E/M note. Proper documentation of the patient’s complaint, his medical history, an examination beyond the ear, and a medical decision to remove the cerumen as well as a treatment plan for the second diagnosis, can legitimize a separate E/M procedure and thus support the use of the 25 modifier.

Step 3: Understand the Patient’s Insurance

Some payers do not consider 69210 to be inclusive or mutually exclusive of an E/M procedure. Others have strict guidelines for how the physician executes the procedure, or they put a cap on how often the service is paid for. Check your payer’s regulations on cerumen removal before billing this service.

Take note: Medicare does not pay for an audiologistto remove impacted cerumen. Therefore, if you are billing Medicare you need to send confirmation that the impacted cerumen removal on the day of audiological services was performed by the physician.

The catch: Medicare will not pay for 69210 and an audiology service on the same day. They require the recoding to G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing service as audiologic function testing) indicating that a physician performed the removal on the day of audiology services. Some private payers also pay this G code.

@ Medical Office Billing & Collections Alert, Editor: Joshua Thines

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Hint: Gathering upfront pay and watching E/Ms make a difference.

Children need physicals to participate in their favorite sports year round, but the demand can grow with warm weather approaching. Ideally, the need for sports physicals should provide the opportunity to offer complete age-appropriate medical exams following the American Academy of Pediatrician’s Bright Futures Guidelines. If your practice runs into reimbursement obstacles for full-scale physicals, however, follow our experts’ advice to code correctly and still stay in the game.

Tackle Coverage Issues

Choosing the diagnosis code for a sports physical is fairly easy. You’ll use V70.3 (Other medical examination for administrative purposes).

Choosing the best CPT code for a sports physical is a bit trickier. “I struggle with this because the service rendered is preventive, but doesn’t meet the criteria (in my opinion) of the preventive medicine E/M codes,” says JoAnne M. Wolf, RHIT, CPC, coding manager for Children’s Physician Network in Minneapolis, Minn.

Here’s why: In most cases, a child coming for a sports physical doesn’t have a chief complaint, so it seems inappropriate to code from the 99201-99215 range (codes for an office or other outpatient visit for the evaluation and management of a new or established patient), Wolf points out.

Although the preventive medicine E/M codes 99381-99397 (codes for initial or periodic comprehensive preventive medicine evaluation and management of an individual) satisfy the requirements for sports physicals, they also seem inappropriate. When the patient only requests a sports physical, the service you provide doesn’t meet the codes’ comprehensive nature.

“Physicals are a very hard topic to discuss because some insurances will not cover them at all and some will cover them in different ways,” says Susie Stokes, CMC, CMOM, practice manager of Morgan Pediatric Group in Smyrna, Tenn.

Common guidelines can include:

• One per calendar year
• One per year following the patient’s birthday
• One after one year and one day after the last physical.

Other complications can arise because of the sports organizations’ rules. For example, Stokes says most school sports in her area require a physical after May 1 of the current year. If the child had a physical before May 1 and the sports league requires it after May 1, the parents have a dilemma: They don’t want to pay for another physical and the insurance provider will not pay.

“In this case we go ahead and sign the form and date it the date of the physical with all the information,” Stokes says. “Then if the association wants another physical, the school explains it to the parents so we don’t look like the bad guys.”

Good practice: Your first step should be to ask patients to pay cash for the sports physical (especially those with insurance you know doesn’t cover the service). If the parent insists that insurance will cover the exam, assure the family that your practice will file a claim and reimburse the parent if insurance does pay.

Pitch Preventive Visit Instead

If the patient’s insurance includes a yearly preventive medicine service, you can offer that service in lieu of the sports physical and maximize the patient’s benefits — pluskeep your coding clean. AAP recommendations supportthis approach.

“Many of our clinics will perform the full preventive medicine service at the time the patient presents for a sports physical,” says Wolf. “Adolescents and teens are age groups that do not tend to come in regularly for their preventive services, so our clinics try to take advantage and get the complete well visit done at that time.”

New tactic: Your coding will change if you’re able to provide a preventive care visit. Choose the best code from 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual …) based on the patient’s age for a new patient or from 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual …) based on the patient’s age for an established patient.

You also have two choices for the preventive examination’s diagnosis. Select V20.2 (Routine infant or child health check) for children up to age 18. For those over 18, shift to V70.0 (Routine general medicalexamination at a health care facility).

Catch Extra Services

Watch for additional coding opportunities with these patients, because a sports physical might extend to include other services.

If the pediatrician provides a problem-oriented E/M service for a separate, significant problem in addition to the sports physical or preventive medicine service, you also can code for it.

Next step: Once you select the appropriate E/M code, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to that E/M code and include documentation supporting the care as an additional service.

You should be able to link the E/M code to a specific diagnosis for the problem addressed, such as 493.00 (Extrinsic asthma; unspecified) for asthma that is well controlled with medication or 314.01 (Attention deficit disorder; with hyperactivity) for ADHD managed with stimulant medications.

Head Off the Competition

Another challenge with sports physicals lies in the ever-growing number of “retail” clinics that offer quicker testing and less costly services. Stokes and Wolf agree,however, that convenience doesn’t equal quality.

“We don’t do what people call the quick sports physical,” Stokes says. “We understand the parents want something fast, but we’re clearing these kids to play sports and we have to take the appropriate amount of time to make sure they’re in good health to play.”

“Many of the primary care pediatric clinics in our network have countered the retail clinics by offering ‘walk-in’ services during regular clinic hours,” Wolf adds. “They also offer extended weekend and evening hours.”

@ Pediatric Coding Alert, Editor: Leigh DeLozier, CPC

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