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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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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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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