Coding Strategy

Choose the service level using the documented history, exam, and MDM.

Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any NPP.

If the provider spends at least half (16 min) of the total session time counseling the patient, then report …… 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity … Physicians typically spend 30 minutes face-to-face with the patient and/or family) for the encounter, based on the total time the provider spent face-to-face with the patient, with 531.7 (Gastric ulcer; chronic without mention of hemorrhage or perforation) appended to represent the patient’s condition.

Don’t stop there: Whenever you invoke the counseling exception for E/Ms, be sure the patient’s medical record has good documentation of the session. For instance, a good note for your scenario might read: “Spent total of 34 minutes with patient. Talked about medication options and possible side effects for 15 minutes, and about diet and ulcer management for 6 minutes.”

Remember: If you cannot enact the counseling exception for this encounter and code based on time, you must code based on the key elements. Choose the service level using the documented level of history, examination, and medical decision making the physician provides. In your case, the visit’s key components would qualify as 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …).

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Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.

Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.

Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.

Watch for Chronic Conditions

“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.

The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.

Be Alert to Counseling Time

When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.

Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused history, an expanded problem focused examination, and low complexity medical decision making, which qualifies as 99213 based on HEM. The pediatrician documents she spends 15 minutes counseling the patient on hypertension management and the visit lasts 25 minutes.

Because counseling comprises the majority of the encounter’s total face-to-face time, you can code the visit using time as the controlling factor and select 99214 (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 detailed history; a detailed examination; medical decision making of moderate complexity … Physicians typically spend 25 minutes face-to-face with the patient and/or family). If you had overlooked this fact and instead coded 99213 based on HEM, you would have sacrificed approximately $31* in pay.

*Note: The 2009 Medicare Physician Fee Schedule, which you can use as a benchmark to judge private payers’ fees, assigns 2.56 relative value units to 99214.

Using the conversion factor of 36.0666, 99214 pays approximately $92. Code 99213 has 1.70 RVUS, which equates to approximately $61.

Heads Up on Other Disorders, Diseases

Some other examples of chronic conditions that might warrant an updated history, exam, and counseling are diabetes (for instance 250.01, Diabetes mellitus without mention of complication; type 1 [juvenile type], not stated as uncontrolled) and ADHD (314.01, Hyperkinetic syndrome of childhood; attention deficit disorder; with hyperactivity).

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Discover what the 5th digit represents and why you need it on your claim.

Question: A presents to the ED with complaints of a headache that’s worsening daily. He is experiencing visual blurring and nausea but no vomiting. This is the third headache of this nature in three weeks, and it has lasted “four or five days.” Documentation indicates a detailed examination and history; after performing the assessment and speaking to the patient, the physician documents migraine with typical aura and status migrainosus Treatment options include acute intervention with prescription, but the physician feels the patient needs to add prophylactic medicine treatments, since the headaches appear to be reoccurring. What migraine ICD-9 code represents this patient’s headache?

Tennessee Subscriber

Answer: This sounds like a migraine with status migrainosus. On the claim, report the following:

• the appropriate-level E/M code based on the notes, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused detailed history; an expanded problem focused detailed examination; and medical decision making of moderate complexity …)
• •346.02 (Migraine with aura; without mention of intractable migraine with status migrainosus) appended to the E/M to represent the patient’s headache
• •368.8 (Other specified visual disturbances) appended to the E/M to represent the patient’s blurred vision
• •787.02 (Nausea alone) appended to the E/M to represent the patient’s nausea.

Explanation: All of the migraine codes now include a fifth digit that indicates presence of status migrainosus. Since your patient reported a four-day migraine, it sounds like the patient was suffering from status migrainosus.

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Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or 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 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

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87 percent error rate leads to drastic measures.

If you think CMS is only watching your E/M codes when it comes to the office or hospital, think again. One MAC recently reviewed nursing facility care claims and was stunned at the findings.

NGS Medicare, a Part B payer in four states, announced on Jan. 26 that it had recently audited claims for code 99310 (Subsequent nursing facility care, per day), and found that only 13 percent of these claims were billed correctly.

Based on the outcome of the audit, NGS said that it “will be implementing a prepay edit for CPT code 99310.”

Know these quick facts before you report this nursing facility care code in the future.

1. Check documentation for comprehensive interval history, comprehensive exam, and/or highcomplexity medical decision-making. CPT requires documentation of at least two of these criteria before you can bill 99310.

“I imagine that doctors are habitually visiting all their nursing home patients at one time and not documenting enough to meet the level-three code,” suggests Crystal S. Reeves, CPC, CPC-H with The Coker Group in Alpharetta, Ga. Indeed, the NGS report indicates that “most errors occurred because the services were billed at a higher level than was substantiated by the documentation.”

2. If you’re coding based on time, be sure to document the pertinent details.

Ever since 2008, CPT has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

“Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter,” says Wendy Owens-Frierson, CHM, CHI, CPC with PRSS, Inc. in Miami, Fla.

Resource: To read the results from the NGS audit, go here.

Look for an in-depth article about time-based E/M coding in next week’s Part B Insider. Download 2 FREE sample issues here.

Available on CD: The biggest mistakes that coders make with nursing facility E/M codes.

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