Urgent Care Coding. Webinar Subscription Access Expires December 31.

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1 Urgent Care Coding Questions Answers Webinar Subscription Access Expires December 31. How long can I access the on demand version? You will find that in the same instructions box you utilized to access this presentation. Subscription access expires December 31, individual purchases will not expire for at least two years. If you are the purchaser, you can find your information through following these steps: 1. Go to & login 2. Go to Purchases/Items 3. Click on Webinars tab 4. Click on Details next to the webinar 5. Find the instructions box in the middle of the page. Click on the link to the item you need (Presentation, MP3 file, Certificate, Quiz) Where can I ask questions after the webinar? The online member forums, where over 100,000 AAPC members have access to help each other with all types of questions. *Forum Posting Instructions* 1.Login to your online account 2.In the middle of the page you will see discussion forums 3.Click on view all top right hand side 4.Select general discussion under medical coding unless you see a topic that suits you more 5.On the top left side of the forum box, you will see a blue button, new thread click on that 6.Type your question and submit 7.Check back in that location for answers as you please

2 will there be a question and answer period following webinar on slide 34 it sas that at least 3 of the 6 elements should be documented. on our research we did not find this statement. can you provide us with your source document. is chief complaint collected by physician or nurse and if nurse can it be used for code selection If a provider orders labs or x-rays and then reviews the tests, can credit be given for both ordering the tests as well as reviewing the tests? Does urgent care have different rules regarding billing separate e/m with a minor procedure? Meaning does the e/m still need to be significant separately identifiable? Our question and answer period is via this chat box during the entire presentation. We do no verbal Q&A after the webinar. CMS, Novitas, ACEP The chief complaint must be documented by the physician. The only elements that can be documented by ancillary staff is the ROS and PFSH but they must be reviewed by the physician in order to count it toward the documentation. It is one point for order and/or review. Only one point is given. If they provider performs an independent interpretation that they do not bill the CPT code for the interpretation, they can get 2 point for the interpretation and 1 point for ordering the test. The E/M still must be significant and separately identifiable in the urgent care setting. Can my doctors use a rubber stamp to sign their records? Please address slide #13 and explain how GI would be ROS Element in this example. where is the tool found? Refer to the CMS guidelines regarding signature stamps, they are not allowed, you would need to check with other payers for their policy. The provider documents responses to nausea, vomiting and hemorrhoid like pain. Novitas

3 What is the reason Lynne said that if it is a severe injury (not sure if I heard right) then we may want to use the 1997 guidelines where do ultrasounds fit in the amt compl data? I was told by an auditor that review/order tests in 9XXXX of CPT had no maximum qty, and we should count every one. Is this correct? Would "team rounds" be a legit element to add to 'data reviewed'- since in essence it's a discussion with performing MDs? If provider is the same one who performs or interprets a test from the 7xxxx section, such as an MRI, does he still get credit for the amount of data reviewed? If a patient with diabetes comes in to UCC with their blood sugar log, how would review of the log be credited towards MDM? If it is a severe injury and the provider does an extensive exam on a particular system, 1997 DGs may be better. It is recommended that you use the DGs that are most advantageous for the provider unless your company has a policy that dictates which guidelines you are required to use. An ultrasound is counted as radiology. All codes are counted as radiology. I have never seen that documented. It is one point per category for labs, radiology and other tests. Some MACs may count it differently. It would depend on how it was documented. If the team rounds is for teaching purposes, no it would not count. If it for providers to collaborate on care of the patient, then yes. He gets credit for ordering the test but since you are billing out the interpretation, you can not get MDM credit for the interpretation or review. Usually the review of the logs is counted as quality in the HPI on the readings the patient gets at home.

4 Question for the speaker what the difference is between the 1 and 2 points for the history from others? Could you share information on the points for babies? Thanks! Where does a tetanus shot fall in the management options selected in the table of risk? We are a Payor - we are seeing that Urgent Cares are billing New patient E&M codes when the patient has been seen at the same UC site, sometimes by a different Physician but many times by the same Physician. We have advised that this is not appropriate. What is your feedback on this issue? what is the definition of 'additional workup planned'? Has CMS defined this? If so, where is the CMS reference? Should MDM be one of the 2 areas counted or selecting E/M for established patients in order to support medical necessity of code selection? how would you determine a cost for billing along with an e/m level do you find that most insurance does not reimburse for the I point for deciding to get the information from others and 2 points if during the encounter they obtain the history from others and include the information in the documentation. For babies, there is no documented guidance for this. The nature of the presenting problem should be considered. I would use the nature of the presenting problem for why the patient needed the tetanus shot. If it is an acute uncomplicated injury it would be low. If it was complicated, it would be moderate. New patient codes should only be billed if the patient has not seen the same specialty of the same group in the last three years. The only way this would be appropriate within the three year time span would be if the providers were from different specialties or subspecialties. Some MACs have defined this. Some require that it is work planned after the encounter. Example: patient sent for diagnostic testing. Others will allow tests performed during the encounter. Some MACs require MDM to be two of the three components but not all. Check with your MAC. You need to determine the cost for offering the service and determine your fee that way. It varies by payer, research is needed to determine who will pay for it.

5 If a provider orders labs/x-rays and then independently reviews these test will he get credit for ordering these tests and then independent review of these same images or specimens? You note that CMS has a general rule for 'additional workup planned'. Can you please describe their 'general rule'. Thank you. If, for example, the CC is "shortness of breath" can it be used for both the CC and ROS? He gets credit for ordering the test but since you are billing out the interpretation, you can not get MDM credit for the interpretation or review. Some MACs have defined this. Some require that it is work planned after the encounter. Example: patient sent for diagnostic testing. Others will allow tests performed during the encounter. If you have not used it as an element the HPI than you could count it as a ROS element. You cannot use the same piece of information as both an HPI and ROS element unless it has been stated twice in the documentation. Our billing is set up thru the clinic that owns our urgent care. If they are Medicaid we bill them as an "11 office" not an "20 Urgent Care". Can we still use the for everyone or just the ones we bill as a "20" You can use in a place of service 11. Can you give an example of the correct way to document an x-ray global charge. Can you please repeat what company and website you referenced regarding the E/M audit sheet. Thank Documentation must include a separate interpretation as would be provided by a specialist and the equipment and staff who performed the X-ray must be an expense for the billing provider. No modifier is appended to the procedure code. Novitas

6 At our UC centers we consider all pts to be "new". Is this because we are considered a class B Emergency room, (affiliated with a hospital)? Since this is the case can we bill an after hors code for pts after 5pm? or does this not apply since weare considered a class B center? Do you have documentation from CMS which demonstrates the requirement of 3 of the 6 elements of the EKG? Can we bill for the interpretation of an EKG if the physician documents that they "agree" with the findings on the printout of the EKG strip? would you bill an e/m level along with application of splint? Do the same documentation guidelines for EKG apply in office setting as well as UCC? does the reading on the ekg count as proper documentation or does the doctor need to restate it on the encounter also If a patient comesin with a laceration and receives a Tetanus with it. Can we bill an E/M along with the laceration repair and Tetanus? she mentioned a Novitis audit sheet. can we get that as an added document to this webinar? what are your sources for x-ray and ekg documentation...specifically regarding the interpretation? Because you are open 24 hours, you should not bill the after hours codes. CMS, Novitas, ACEP No, it must be an interpretation. The computer read is part of the technical component. Answer: Yes, you can bill splint care with a modifier 25 on the E/M level. Yes, documentation guidelines for EKG apply in all setting. The interpretation can be written on the EKG tracing. Yes, as long as the E/M is significant and separately identifiable. answer - yes I will send the link to the AAPC and they can make it available to you This can be found on the CMS website

7 WHAT IF YOU HAVE AN ORTHO DR ON SITE AND TRANSFER CARE TO ORTHO HOW WOULD YOU BILL? The UC doctor bills for the service they performed and the Ortho bills for the services they performed. If they are different specialties it should not cause a problem. Some payers only allow one E/M per group. In that case, combine the documentation from both providers to determine the E/M level. If the doctors are not in the same group, then the services can be billed separately without a problem. Our facility is urgent care and we also have Podiatry, Physical Therapy, Optometry and Dental. So, a patient was seen in Urgent care and is referred to Podiatry, does the Podiatry visit become a new patient visit or does that fall under sub-specialty and would be considered established? if physician fabricates splint and applies can you bill e/m level and application of splint if there was no other issues other than the fracture itself Can you expound on "Independent visualization of Image, Trace, Specimen" as opposed to "Review/Order Tests?" what are the requirements in the documentation to bill for fx care... what would the physician HAVE to state in their procedure note? If the provider they saw in the UC is not the same specialty they are referred to then it would be a new patient. If they are the same specialty or subspecialty, it is an established patient. If there is a significant and separate E/M then you can bill both services. [11:39 am] Nicole Benjamin: Answer: Independent visualization of Image, Trace, Specimen is when a physician is interpreting the test and that interpretation from the provider is documented in the record. It must be definitive care to treat the fracture. If the provider is placing a cast for temporary care until the patient can be seen by a specialist, it would be billed as a splint/strapping-not fracture care.

8 Does the documentation of the pro fee component, to meet billing requirements for 93000, have to be written in a separate report, or can it be included as part of the MD's note in the Urgent Care record? It is our understanding that we can only bill for splinting services IF the provider at minimum starts the process - is this accurate or can we bill for the service if a M.A. performs the service? It can be written in the note. The your state's scope of practice allow an MA to perform the procedure? In a facility setting, it must be performed by the MD because incident to does not apply. If in the office setting or UC that does not fall under an ED site of service, ancillary staff can perform services under the supervision of the MD as long as it is within the scope of practice of the individual performing the service. I am confused on the data points. Labs/X-rays ordered and/or reviewed are one point regardless of the # ordered. So are you saying that if the physician orders and is the one to review the test, then you are to count 2? The Medicine does not seem to specify regardless of # ordered; I believe this is why the auditor I spoke to said to count each one as a separate data point. Each one is a different "section". Any lab(s) ordered or reviewed is 1 point, regardless of the number. Any X- ray(s) ordered or reviewed is worth 1 point. Any test(s) from the Medicine section ordered or reviewed is worth 1 point. EXAMPLES: If 3 labs are ordered - 1 point. If 2 labs and 1 x-ray are ordered - 2 points (1 for the labs and 1 for the x-ray). If 4 labs, an x-ray, an ultrasound, and an ECG are ordered - 3 points (1 for the labs, 1 for the x-ray and US, and 1 for the ECG). Would "team rounds" be a legit element to add to 'data reviewed'- since in essence it's a discussion with performing MDs? It would depend on how it was documented. If the team rounds is for teaching purposes, no it would not count. If it for providers to collaborate on care of the patient, then yes.

9 if patient has been seen in ER or outpatient clinic in hospital and our urgent care is owned by the hospital is this an established patient? we splint distal radial fx's all day... no cast just a splint but the doc applies it... are you saying we shouldn't bill b/c they are told to see ortho for follow-up but we don't know that they do or not... and sometimes they follow-up in urgent care regardless of what they were instructed answer - It sounds like they would be an established patient but I always check to see if the providers share the same tax ID employment( at both the UCC and the ED) and also check to see if they are incorporated separately. It depends on the intent of the splint. Is it a temporary measure until the patient can be seen by the orthopedic or is it definitive care? If it is meant to be a temporary treatment to stabilize or provide comfort to the patient with the intent for the patient to seek definitive care from Ortho, bill it as a splint and not as fracture care. If one test is ordered and it is reviewed by the same provider during the same encounter, will that be counted as 2 data points or 1 under the medicine section? If a patient comesin with a laceration and receives a Tetanus with it. Can we bill an E/M along with the laceration repair and Tetanus? When a provider orders and reviews the a lab test only one point is counted. That would depend on the documentation and what the provider did at that particular visit for that patient. All surgery codes include (per CPT guidelines) subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure. What is separate from the 65220? in the mod 25 example. thanks Isn't the initial evaluation included in a minor procedure?

10 how important is it to add location modifiers such as LT for left eye? Some payers consider location modifiers as informational. But in some cases, they may assist in the adjudication process. If a patient presented for a procedure/service on the left side and then returned for a procedure on the right side (same procedure) the RT/LT may help indicate an important point to the payer. For time based encounters does documentation need to state both total time face to face and the amount of time spent in counseling/coordination of care? is greater than 50% of total time spent counseling/coordination of care acceptable? Yes, but remember in the guidelines the provider must also state the nature of the counseling. So, "30 minutes total face-to-face time spent with the patient, with more than half that time spent counseling the patient regarding " If any separately billable procedures are performed, also remember to state that time was not counted in the total face-to-face time for the code selection. are there instances when it would be inappropriate to bill an e/m level along with a procedure code can you bill for both even if ICD9 code is the same for EM and surgical procedure? how do you determine if you use static or dynamic splint codes? If the patient presented for a planned procedure the E/M, if only related to the procedure performed, would be bundled in to the procedure. Yes you can. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim. If you are asking the difference, static splints immobilize and dynamic splints provide mobilization. If you are unsure which type was applied, you may want to check the manufacturer or ask the nurse or doctor.

11 when would a diagnosis follow up care code be assigned when would a diagnosis follow up care code be assigned this shows V72.5 for Lab and V72.6X for x-ray, we are doing just the opposite, we are using V72.5 for x-rays Is covered by Medicare? We can use the even with the Medicaid patients? what would be coded and billed for a sports physical, dot physical etc, in addition to the above fx question... we are billing the fx care with a 54 and the e/m with a when we are doing the fx care at the UCC is that correct then... or do we still need to only be billing the splinting code? The follow up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. Routine postpartum visit is an example of a follow up code. SAME QUESTION AS ABOVE V72.5 is for Radiologic exam and V72.6X is for Laboratory exams. We apologize for any confusion. The MPFSDB shows with a $0 value. If a service is performed and documented that has a specific CPT code, that code may be reported. Whether or not a payer accepts that code and covers it for payment is a different issue. It depends on the payer. Some require it be reported as a preventive and others require an EM code. Reading or ordering and EKG equals one medical decision making int by documenting I am assuming you mean writing down their interpretation which equals two MDM points and is possible a billable service in addition to the E/M

12 We have two providers that work rotating shifts at our office. We had a patient come in with an abscess that had to be drained on multiple follow ups. They were seen by both providers at different visits. What modifier should we use? If the providers are the same specialty and share a tax id, they would be considered the same provider. Modifier 58 for staged/related procedure appears to be the appropriate modifier without seeing any documentation. If you are in an office setting and not UCC can you still use the for extended hours and federal holidays? both components please show documentation to prove that 26 and tc are required please In your coding scenario on slide 42-43, why is the office visit considered separate, significant from the procedure. Does this hx and exam go above and beyond what would normally be required for the procedure? Yes, but not all payers recognize the code for payment. If you are billing the global service, you do not need to append 26 and TC. You only use the modifiers if you are only billing one of the components of the test. In the example it states the level of history, exam and MDM documented in addition to the procedure. Yes the E/M in this example would warrant a separate E/M. We tried using the in our system and it said it was not billable separate because it is part of the E/M code. dr IS EMPLOYEE OF THE URGENT CARE, URGENT OWNES RADIOLOGY EQUIPEMENT IS -26 APPROPRIATE TO USE? When you have global contracts with the some payers, what are the typical carve out procedures that we can bill for outside of s9083? is a major procedure which carries 90 global days. I can see no reason that the system would state it was bundled in to the E/M. if you both own the equipment and the provider is employed by who owns the equipment then no modifier is needed. You are providing both the technical and professional components. It depends on the contract, but most UC will get X-rays, complex laceration treatment, and simple fractures in the carve-out.

13 We are told buddy taping is not a separate billable service from an E/M- thoughts? What would be the appropriate code/modifiers to use when providing fracture care in the ED or UC setting and the follow-up is done by an ortho dr. that is in the same group practice and using the same tax ID number as the ED physician? We have been advised that the MDM drives the E&M code, and should always be considered as one of the two components required for established patients. Do you agree? As with some issues, payer policies may vary. Although they share the same tax id, they are different specialties. The UC provider would use modifiers 54 and 56 for the surgical care and preop. The Ortho provider would use the modifier 55 for postop care. There are some carriers that do require the MDM to be counted as one of the two components, but it is not a requirement by all. You may want to check with your carrier and make a policy regarding how your facility will regard the issue is not covered by Medicare.. The MPFSDB shows with a $0 value. how do you decide when you are going to bill and code an A good rule of thumb may be to take out the portion of the e/m level along with a procedure code E/M that is directly related to the procedure and see if there is enough left to level a separate E/M service (if it is medically necessary). Slide 47 and 48 - Surgical Care - Is fracture care considered a surgical procedure (i.e buddy taping the toes)? Yes, fracture care is considered a surgical procedure. do you have any additional information regarding billing of additional supplies and billing for IV/medications? I thought this was going to be addressed in the webinar. Thank you. Supplies included in providing procedures would not be billed separately. The medications administered should be reported with the appropriate HCPCS Level II codes and administration codes.

14 Does a modifier 25 need to be appended to the E/M when a therapeutic injection is given and or a nebulizer treatment is performed if theses procedures are based on the patient's chief complaint? Modifier 51 - is it required by Medicare to use this modifier for 2 or more procedures? Or, is it alright to bill multiple procedures without? if the splint supply has a HCPCS code that includes fitting and adjustment would you bill an e/m level along with the HCPCS code answer - While technically not required, some payers do require modifier 25 be added to E/M code when other services are billed. Your best bet is always to check with the carrier for their specific policies. Some carriers no longer require modifier 51 as the multiple procedure reduction is automatically appended through the adjudication process. Check with your carrier to see if they require it. I am assuming you are referring to the splint CPT code and not the E/M level. Yes you could bill for the professional service and the supply ( the splint itself). Please review the durable goods licensing rules. our physician is convinced that by having team rounds - this will somehow add more MDM. He is under the belief that his time spent with the patient's family and discussing the patient in team rounds somehow can add to oen of the elements thusly allowing for a higher cod. We beleive that only time based codes (face to face time) can allow for that The only way it would add more time is if it was to counsel or coordinate care. If the team rounds is to discuss the care and recommendations from other specialists it could increase MDM. Without seeing documentation, it is difficult to provide a definitive answer for you. Please explain how you can use the modifiers in slide 48? Modifier 54 is used on the surgical code as the UC provider will not be providing the global care for the fracture, but is sending the patient to Ortho for continued care. The code for the fracture care carries a 90 global period; therefore the modifier 57 would be necessary to append to the E/M to indicate the decision for the procedure.

15 what dx code would you use if physician dx is dental pain For dental pain I have used code Do the same documentation guidelines for EKG apply in office setting as well as UCC? WE ARE GETITING TWQVA If a patient comesin with a laceration and receives a Tetanus with it. Can we bill an E/M along with the laceration repair and Tetanus? Is there a difference between buddy taping a fractured toe, placing it in a boot, and sending the pt to a orthopedic for follow-up care and a fractured radius being placed in a short arm cast with follow-up with an orthopedic? what are your sources for x-ray and ekg documentation...specifically regarding the interpretation? If patient was seen and diagnose with an URI and then sent home with a prescription and then 30 days later patient comes back in for same condition would you consider this URI as an established Dx worsening or a new dx?? yes The code is for open fracture care. Not appropriate for this example. Yes - add the modifier 25 to the E/M and you will need all the elements documented to support the LOS you bill. It depends on the intent of the treatment. If it is definitive it is fracture care. If a temporary to allow the patient time to go to the Ortho, it would not be fracture care. CMS, Novitas, ACEP It would depend on how it was documented. If the original URI had cleared up and the patient now presents with a new URI, then it would be a new problem. If it was a lingering, never going away condition that the patient is returning for, then I would look at established worsening. It is all in the documentation and each case can be different.

16 does the reading on the ekg count as proper documentation or does the doctor need to restate it on the encounter also Do the same documentation guidelines for EKG apply in office setting as well as UCC? - yes It is my understanding that if the office or facility advertises their business hours with hours past 9am-5pm that the extended hour code cannot be billed. Is this correct? This would also included advertising being open on Saturdays as well Reading or ordering and EKG equals one medical decision making int by documenting I am assuming you mean writing down their interpretation which equals two MDM points and is possible a billable service in addition to the E/M Yes I am unsure of which code you are referring, but: states other than regularly scheduled office hours, it does not state a requirement on those hours states during regularly schedule hours in the evening, weekend, or holiday, it does not state a time Maybe the person was referring to versus 99051?