Message If established pt wouldn't 2 out of 3 still require the level for slide 5? Response Message Can you re-state your question? I am unclear on what you are asking. Thanks You stated that even when the e/m code requires just 2 key components, that all 3 must be documented. where would we find that requirement? When working with NPPs it is difficult to get them to understand documenting what is pertinent to the current visit. Do you have any references that might assist us? I 1995 guidelines only state constitutional does this require 3 vitals to be examined. Would an infected bug bite or strep throat be considered a selflimited/minor problem or a new problem, no additional work up planned? I have a medical record in front of me that says Chief complaint- "I had a stroke"- does that seem appropriate? Because hospital inpt, we would need all 3 requirements is this correct? CMS indicates a provider should document the work performed Check with your MAC; they may have guidance on their website. 1995 does not require documentation of 3 vitals, 1997 guidelines require that I would want to see the documentation on the specific visit. If it is an infection related problem, it would probably warrant higher decision making than self-limited. Did they give any additional signs or symptoms? It is the problem, stated in the patient's own words. You would expect to find further details in the history of present illness. Inpatient admit code would require 3 elements, subsequent daily visits only require 2 of 3 An oncologist meets with a patient prior to initiating chemotherapy. Level of MDM does not have data to review. Also the patient is stable (though very ill) & the discussion of chemo options is extensive. Time does not qualify for level 4 (because "he knows the patient") though provider doesn't agree when "points" for MDM result in only low MDM and level 3. Could a reviewer allow a level 4? Please explain in detail the differences between excision of lesions, shave removals, & destruction. The provider's documentation would need to support the level of service. When I audit and find this, I will talk to the provider We will get to that shortly If the Dr states that all other Review of Systems are negative is that acceptable? When time is more than 50% of the visit because of counseling of a diagnosis given, how is it decided with the 3 out of 3 theory? Currently it is being accepted by CMS; however, check with your local carriers and insurance companies to see if they consider it allowable. The provider would still document the service performed; if the elements meet a higher level of service than time, you would code the visit on the elements instead of time.
The Guidelines you are referring to are which Guidelines? For ENT, do you feel when they use MMM is enough to count? It was in quotes as if the pt had said it Which slide are you referring to? MMM can represent many different things; what is it being used to represent? Is there something about it that concerns you? I would allow it and assume there would be further development in the HPI. Is it possible to have a 99215 with only 2 DX documented? Do the number of DX correlate with any of the levels of the 3 key components of the code? It would depend on the severity of the of the problems. I'm a little bit ahead of you, but have specific questions regarding things covered today; 1. Joint Injections, if anesthetic type meds are used, ie lidocaine/marcaine not to prepare the site, but as the injected med, you can charge for it, but if mixed with another med, ie Depo-Medrol/Marcaine mixed, would you only charge for the Depo-Medrol or both? Q2. re: carve out, Medicare patient presents for routine 2 yr gyn exam & pap, at the visit complains of urinary incontinence, found prolapse & cystocele, physician treats, can e/m also be charged, since the focus of the exam is on the same body system? We have a physician who spends a large amount of time removing the impacted cerumen by irrigation. He says it takes a lot more time compared to if he could remove it with a curette. If his documentation supports his rationale including the amount of work it took him would that qualify for 69210? 1. Correct 2. You may need to check with your MAC, it is a problem, in my opinion, it should be separately identifiable as a problem. Irrigation alone may not support cerumen removal; I would check with your specific payers to find out what their policy indicates. 69210 reported once for both ears? CPT description indicates one or both ears Does the 3 + chronic or inactive conditions (for HPI) apply to both the '95 & Our carrier, WPS, allows this for both 95 and 97 guidelines. I would check '97 guidelines? with your local carrier. On Hospital Observation patients if there is not enough documentation. Is it appropriate to assign 99218 since it is the lowest code for this situation? The provider documents "denied" for components in HPI. Ex. onset/timingdenied, location-denied, etc. The reason for visit is f/u CAD, HTN, and BPH. How do I count the HPI? Documentation would need to support 99218; otherwise use an unlisted code. Does the provider give further detail on any of the conditions? If not, I would have a hard time giving credit for HPI.
I recently saw a question in the CPT assistant stating it is not an incision if a needle is used for incision and drainage. It stated this would fall under the E/M code. If the documentation supports the provider did indeed do an incision with the needle shouldn't that qualify for coding the procedure separate? I would question if it is truly an incision or puncture. It does sound like it would be part of the E/M. Code 93000 done with a pre op v code does there need to be an additional dx to justify why 93000 is being done if the patient has history? Are you saying that 69210 and G0268 are interchangeable, or would you use the HCPCS code when billing CMS (Medicare plans) only? Is documentation guidelines any different for a specialist than for a primary care dr? Just wanted to be sure it meets criteria is all- that's what concerns me So it is not appropriate to use the pathlab for the size, just for the type of lesion it is? Once you go back to the physician for clarification, don't they have to put in an addendum to the medical record? If the provider forgets to include the size of a lesion is it ok to have them add a clarification or late entry? Are you saying that Medicare will not pay a 99212 with an Admin code? I might have missed it but these instructions are geared to a physician office (free standing) not out patient hospital. Sometimes people listening will go back in an out patient hosp setting and start billing the drugs. What about billing the unlisted code (J3490)? do these claims need to be billed w/ an invoice (to Medicare), or do comments within the claim suffice (drug, dosage, etc)? What if the documentation only indicates the name of the drug, "Toradol given". Do give credit in the MDM? For an excisional shave bx, would you use the shave codes or bx codes? Is this a facility requirement prior to procedure? If not, you would expect a supporting diagnosis to show medical necessity. The description for G0268 states "on same date of service as audiologic function testing" ny provider can use any of the 1997 specialty exams, the guidelines are the same for all specialties. E/M guidelines state a concise statement, sometimes in the patient's own words The documentation in the medical record should indicate the size of lesion. If it does not, I would first talk to the provider so they understand the importance of the documentation of size. Yes, they should indicate the size was added (dated entry). I would recommend the addendum prior to the claim being submitted. Yes, they should indicate the size was added (dated entry). I would recommend the addendum prior to the claim being submitted. You will need to check with your individual Medicare carrier. You are correct; the guidance is for a physician practice, not facility. You should be able to indicate the dosage, drug, etc. on the claim I would query the provider for dosage, location, etc. Was the intent to biopsy for clarification of the lesion? If so, biopsy.
Our allergists do food allergy testing on children. Is it appropriate to bill an office visit to discuss the results with a parent when the child is not present? Or, does the child/patient need to be present in order to bill an E/M visit? Can the carve out time be time-based? If a person comes in for physical but states they have been depressed and the provider spends a lot of time on this. Hi Brenda, can we use cpt 99024 in ED when the patient comes into ER for suture removal within global period. please advise Is lancing & draining of blisters considered to be 10060/10061? We work for a CAH hospital and we have been told by consulting firm that as a Physician we do NOT code diagnosis codes per day for our E/M codes, but instead code the diagnosis as a whole stay using the more definitive diagnosis, even though we are coding daily E/M codes. Is that correct? In order to bill an E/M service, there should be a face-to-face encounter. I have not seen anything to indicate it can be time based. It would be advisable for the provider to turn the visit into a "sick" visit and perform the preventive service at a later date. Did the ED provider place the stitches? If so, yes. I would want to see what the documentation indicates. If it being done by simply puncturing the blister and allowing it to drain, I would not consider that incision and drainage. I would like to research since this is specific to CAH. For a regular inpatient encounter, you do not need to wait to submit the entire stay at once. Hi Brenda please let me know whether it is appropriate to use 99024 in the ER when the patient comes in ER for suture removal within global period What is a Carve Out? Why subtract out the $40? Are the slides stuck? by "usual fee" for the 99212, is that the practice's typical charge or Medicare allowable? The carve out doesn't make sense because Medicare doesn't offer preventative medicine, so how would I charge the pt? Addressed in earlier question above. Slides 23-26 explain Carve Out; CMS will have further information. It is the portion for the problem focused visit you are submitting to the insurance. Everything is functioning perfectly on our end. If you are experiencing difficulties, please refresh your screen. Allowable The carve-out allows you to bill Medicare for the problem focused visit and the patient for the preventive portion. For ROS, if a provider keeps a template of all the systems listed with a ( ) beside each and they only put (+) and they have a notation all negative unless noted above. How would you count that if the patient is only coming in for a simple problem that does not require all systems being reviewed. I would educate the provider that ROS is pertinent to the presenting problem. I would query the provider why a more comprehensive review of systems is required.
On Slide #19, The wordage of "Appears to be Sebaceous Cyst" Would you actually code a sebaceous cyst or cyst? For diagnosis? What was the # of the Medicare notice regarding 99211 not being paid separately from administrations. I only got 100.20 100-20 transmittal 34 What CPT would you use for the cyst removal when no size of defect is indicated? Incident to in a hospital setting can the visit be done by both NP and MD and billed under the MD If a patient presents for an annual preventive medicine exam, is the physician required to document the extent of the exam performed? Are vitals sufficient? Can we bill "incident to" in a nursing home? Is injection of intertarsal joints (i.e. cuneiform) coded as 20600 or 20605? Can the md be 100 yards away but in another building? Can a certified diabetic educator bill incident to with codes 99212-99215 based on documentation? Can we use 99024 when the patient comes into ER for the removal of sutures within the global period Can a nurse Practitioner treat a Medicare patient for a cold or sore throat? regarding the 'carve outs': in the formula as to what you can charge the patient, the slide says the "usual fee" for 99212 - is that the doctor's typical fee or the Medicare allowable? thank you! Why would we not bill with a 51 modifier in a ASC setting? CPT states that 20600-20610 are for aspiration and/or injection-it is not appropriate to report both, right? The provider should be queried for the size prior to removal. Coding to the lowest code of a given range should only be used as a last resort. Incident to applies to the office setting A preventive medicine visit an age appropriate examination; I would expect to see documentation of more than simply vital signs. In a skilled nursing facility, services provided by an employee of a physician can be reimbursed as incident-to when there is "over the shoulderelbow-to-elbow" supervision. If the physician is not present in the room, physician extenders should use their own provider numbers to bill Medicare. (Coding Answer Book) Good question! I'd like to research it to give you the correct information. "In the same office suite" is the definition by CMS. In order to bill E/M services, the provider must be recognized as indicated in CPT. Answered in previous question (posted three times) If you are speaking of incident to, not if it is a new patient and not for a new problem. Allowable CPT has an approved modifiers list for ASC hospital outpatient use, modifier 51 is not included And/or indicates it is billed once for aspiration, injection or both
How about marital status for family history? I have always taught family history as it relates to the condition being treated. In the HPI, if a patient denies any associated symptoms, could that still be counted? Did I miss 3 chronic condition gray area? Family history as it relates to the condition is correct; however, if the spouse's side has something contagious that could be relevant, I would count it. I would give credit for specifically indicated symptoms, I would rather see it worded this way. CMS has indicated You may use the status of three or more chronic conditions to score an "extended" history of present illness (HPI), even if you're using the 1995 E/M documentation guidelines. The Centers for Medicare & Medicaid Services (CMS) gives the OK, and the American Medical Assoc. (AMA) defers to CMS. Can you please clarify on the joint injection - if this was planned to attempt to aspirate and fluid was not withdrawn and then medication was injected would you code 20605 twice? or if aspiration was performed and the injection performed after would you code this twice It is coded one time Can the statement "NAD, alert and oriented" count for both constitutional (NAD) and psych (alert and oriented} I would give credit for both as you have indicated. Last page says substance use not abuse, but the presenter skipped it, if it There is not a code difference; it is mentioned as a clarification for the shows "see abuse" in the ICD-9 what is the difference? documentation in the medical record. Would the statement "he went had a CT scan at the hospital and it was neg" - can this be used as "context under ROS? Context would be under HPI Is there any instance when 96372 would be charged with an e/m same day According to NCCI edits, 99213 is a column 1 component of 96372 but a (in addition to charge for the meds) modifier can be appended to differentiate the service
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 Re: neoplasms, if a patient came and had a lesion removed, the path lab says its malignant and further margins are removed a few days later, how is the margin removal coded??? The additional margin size as noted by the provider