Coding Strategy

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 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 …).

The 99285 code pays about $171 nationally (4.74 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846), whereas 99291 garners about $217 (5.99 RVUs multiplied by 36.0846).

Check Out This Critical Caveat Scenario

We asked Michael Lemanski MD, emergency department billing director at Baystate Medical Center in Springfield, Mass., to describe a scenario in which the physician provides critical care to a patient who also qualifies for the emergency department caveat:

Emergency medical services (EMS) presents with two teenage girls that were involved in a high-speed motor vehicle crash with roll-over. One of the girls has been extricated, has a traumatic amputation of her left arm, and lost vital signs en route to the ED. The other has a head injury, is hypotensive, and appears too intoxicated to provide any history for either patient. The girl who lost vitals en route is clearly critically injured, but the only history available to the physician is when the collision occurred, where, and how. Details about past medical history, social history, family history and review of systems (ROS) are unavailable. The physician spends a total of 64 minutes providing critical care services for the patient.

Caveat achieved, but …: In this instance, the emergency department physician could reasonably invoke the emergency department caveat — but it is unnecessary, as you should report 99291 for this encounter.

@ Emergency Department Coding Alert (Editor: Chris Boucher, CPC).

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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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These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

• 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 …)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
• 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

• 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
• 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
• 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for “normal” newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233) are for problem-oriented services, Moore says.

Since both sets of services are designated as “per day,”coders must choose between them for a given patient on a given date. “Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits,” Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

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

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Hint: You might not need as many codes on the claim as you expect.

CPT 2010 lists several codes for spirometry testing under “Other Procedures” in the Medicine section. The next time you’re faced with determining the best code for a patient, be sure you know the differences between these most-common options — and which codes you don’t need to include on your claim.

Look to 94010 As Your First Choice

When coding spirometry, the most frequent choice for most pediatricians is 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

Scenario: An established patient presents for a follow-up visit after an episode of respiratory distress where she needed a nebulizer or inhaler treatment. The staff evaluates the child’s respiratory status at that visit and treats the child. You report 94010 along with an E/M code for the office visit; experts say the child’s significant subsequent management merits 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 …).

“You don’t usually do spirometry when the patient is in acute distress because the reading will be low,” says Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. “You complete a spirometry test when the patient is stable, usually in a follow-up visit.”

Distinction: Providers sometimes struggle with how to bill for peak expository flow and wonder if they can report 94010 for the service. This is incorrect, because peak flow measurement (using a peak flow meter) is considered part of the E/M service. Spirometry, by contrast, is using a standardized instrument with a hard copy report and interpretation that becomes part of the patient’s record, Tuck explains.

Go Straight to 94060 for Pre- and Post-Tests

Sometimes a single treatment or test is enough; the pediatrician wants more information. In that case, she’ll administer a simple spirometry test, treat the patient with an inhaled bronchodilator, and conduct a follow-up spirometry test. This pre/post test approach is useful in establishing an asthma diagnosis.

“When we do a pre/post test, we use code 94060,” says Suzanne Wood, CPC, with Pulmonary Associates Medical Group in La Mesa, Cal. Again, report 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) with the appropriate E/M code.

Modifier tip: When the pediatrician completes a service in addition to E/M care, payers often require you to 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 the E/M code. Wood and other coders, however, find that including modifier 25 with 94010 and 94016 is unnecessary. “I have no trouble getting paid in addition to an E/M service and I do not need to use a 25 modifier,” Wood says. Check your payer’s guidelines before filing your claim.

Supervision status: Code 94060 requires direct supervision. Ensure that a physician is present in the office suite and is immediately available to furnish assistance and direction throughout the procedure as needed.

Watch for Chances to Use 94664

Patients who use inhalers on a regular basis need to know they’re using the equipment correctly, especially when you’re dealing with children.

“If the child comes in for a well visit, ask how they use their inhaler,” suggests Victoria S. Jackson, a practice management consultant with JCM Inc. in California. “Show them how to use it correctly if necessary and report 94664.”

A trained non-physician practitioner (NPP) or physician can perform the demonstration. Provideappropriate documentation in either situation, and have the supervising physician countersign the NPP’s notes.

Bonus: Taking that simple step with your established patients can garner extra pay each time you report 94664 (Demonstration and/or evaluation ofpatient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). To find out how, subscribe to the Pediatric Coding Alert. Editor: Leigh DeLozier, CPC.

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Even though Medicare no longer accepts consult codes, you can still apply modifier 57.

Question: In our ob-gyn office, we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn’t accept consult codes, how should we use this modifier?

Kentucky Subscriber

Answer: The short answer is that you should appendmodifier 57 (Decision for surgery) to the non-consult inpatient E/M code that the documentation supports.

Suppose the ob-gyn performed a 2009 level-three inpatient consult in which the ob-gyn determined the patient required an exploratory laparotomy later that sameday due to severe abdominal distention and pain as well as some uterine bleeding. Adding the modifier to the E/M code will help show payers why you’re reporting an EM in addition to the major surgery performed later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).

For 2010, the exact E&M code you choose will depend on the circumstances specific to the visit, such as whether the visit is the first or second ob-gyn visit during the admission. But as an example, suppose you’re coding the ob-gyn’s first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity …), which has requirements similar to 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity).

You should append modifier 57 to the E/M code. If, instead, the ob-gyn is the principal physician — the one overseeing the patient’s care and the one who is admitting the patient — be sure to append modifier AI (Principal physician of record), as well. This would be the case if the ob-gyn admitted the patient for observation for the abdominal pain and bleeding but later made the decision to take her to surgery that same day.

@ Ob-gyn Coding Alert, Editor: Suzanne Leder, BA, M. Phil., CPC, COBGC

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