UPDATE Post op care and hospitalists after the consult changesDecember 17th, 2009 - Codapedia Editor
Change: December 15, 2009--Good news!
The consult change would seem to allow hospitalists to bill for post op care using the initial hospital care codes. Here is a post by Seth Canterbury, published with his kind permission, about the topic.
I read it to allow everyone's initial inpatient visit...CPT® Consult Rule Changes for 2010November 2nd, 2009 - Codapedia Editor
By now you've heard the news that starting January 1, 2010, Medicare will no longer reimburse consultation services billed with codes 99241--99245, 99251--99255. But, the consult codes remain in the CPT® book for 2010. However, there is quite a bit of new editorial material related to...Primary Care Billing ProfilesOctober 14th, 2009 - Codapedia Editor
For most primary care physicians, Evaluation and Management services comprise the highest percentage of services performed, and account for most of the revenue. Primary care physicians should regularly compare their profile with the norm for their specialty. These specialty norms are included as a...Observation initial services September 8th, 2009 - Codapedia Editor
Observation services are a status of admission to the hospital. Patients who are admitted to the hospital are admitted either to inpatient status or observation status. The status is determined by the physician, although often the case manager at the hospital will have significant input into the...Prolonged services for office and outpatient visitsJuly 31st, 2009 - Codapedia Editor
This is an article describing using prolonged services codes in an office setting. There is a separate article in Codapedia about using prolonged services codes in an inpatient setting. There is an article describing using non-face-to-face codes, as well.
Prolonged services codes are add-on...G0101 Pelvic and breast examJuly 6th, 2009 - Codapedia Editor
Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.)
Medicare does pay for a screening pelvic and breast...Chemotherapy Infusion and E/M on the same dayJuly 3rd, 2009 - Codapedia Editor
Is it appropriate to bill an E/M service with a chemotherapy infusion?
Here is how Nancy Maguire answered that question:
If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...Nurse visits in provider based clinicsMay 27th, 2009 - Codapedia Editor
Question: Can you bill a nurse visit, 99211, to Medicare in a Provider Based Entity?
Answer: You may not bill a nurse visit to Part B, for a physician service, but may bill a facility fee for a nurse visit in a PBE.
The payment rules for a free-standing,...ROS ChecklistApril 22nd, 2009 - Rikki Runyon
Review of Systems
? Weight loss or gain ? Fatigue ? Fever or chills
? Weakness ? Trouble sleeping
? Rashes ...Services in an assisted living facilityApril 22nd, 2009 - Codapedia Editor
According to the CPT® book, assisted living services are reported with codes 99324--99337. Look at that series of codes for new or established patients. It is not correct to bill at an assisted living facility with office visit codes. These codes are used for services provided in: domiciliary,...E/M service with no examApril 13th, 2009 - Codapedia Editor
Does an E/M service require an exam? It depends on the category of service.
Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level...Incident to Billing or Incident to ServiceApril 10th, 2009 - Jeannie Cagle, BSN RN CPC
By Jeannie Cagle, BSN, RN, CPC
This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...Category of outpatient servicesApril 10th, 2009 - Codapedia Editor
New patient codes 99201–99205 may be billed in an office, outpatient department or Emergency Department.
What is a new patient?
The CPT® and Medicare (CMS) definition are the same. From the CPT® book:
A new patient is one who has not received any professional services from the...Department of Transportation DOT examsMarch 31st, 2009 - Codapedia Editor
How does a physician report performing a Department of Transportation physical? With CPT® code 99455 and ICD-9 code V70.5, 99455 is for a work related or medical disability examination by the treating physician. (9945 is for this examination by other than the treating physician.) See the...Suture removalMarch 30th, 2009 - Codapedia Editor
If a physician removes sutures that he/she placed, and the service has a ten day global period, there is no separate payment for the suture removal. It is part of the global service and payment for the minor procedure.
However, insurance companies will pay for suture removal performed by a...Do headings matter in an E/M noteMarch 30th, 2009 - Codapedia Editor
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical,...Is time the trump card in selecting an E/M service?March 29th, 2009 - Codapedia Editor
Is time a trump card in selecting an Evaluation and Management service?
Sometimes. Isn't that too frequently the answer in coding?
If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes.
The criteria are:
...Is medical decision making a trump card in E/M services?March 29th, 2009 - Codapedia Editor
Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient. After all, isn't a patient with a brain cancer really sick? Shouldn't that patient always be charged a high level...Second opinions: are they consults?March 27th, 2009 - Codapedia Editor
There are no longer any CPT® codes for confirmatory consults. If a patient presents to the office with a request for a second opinion, how is that billed?
If the patient is requesting a second opinion, bill that service as a new or established patient, whichever category is correct for that...Ventilator managementMarch 18th, 2009 - Codapedia Editor
There are two codes for ventilator management for inpatient services: 94002 and 94003. One is for the day when the physician initiates vent management and the second is for a subsequent day. They are mutually exclusive codes in the CCI edits and may not be billed together on the same day. See the...Can a physician be paid for reviewing old records and x-raysMarch 13th, 2009 - Codapedia Editor
A patient presents to the office with 100 pages of old records and a dozen x-ray copies to review prior to consultation. How can a physician be paid for that?
There is no separate reimbursement for record review. With the development of RBRVS, the pre and post work of services is included in the...Can consults be billed based on time?March 12th, 2009 - Codapedia Editor
Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met.
CPT® tells us that a physician or NPP may use time to select a code when counseing "dominates" the visit. CMS confirms these rules in their Documentation Guidelines....Coding for visits to patients in Swing BedsMarch 12th, 2009 - Codapedia Editor
Physicians should bill for patients in facilities based on the status of the patient in the facility. This is true for Observation, Inpatient and nursing facility status. The status billed by the facility and the E/M codes selected and reported by the physician should match.
Some hospitals have...Initial hospital services that dont meet 99221March 10th, 2009 - Codapedia Editor
Sometimes, when auditing an initial hospital service, either the history or the exam does not meet the level required for the lowest level of initial hospital service. 99221 requires all three of: a detailed history, a detailed exam and straightforward or low medical decision making. The MDM is...Can prolonged services be added to preventive medicine codes?March 9th, 2009 - Codapedia Editor
There are two sets of prolonged services codes, one set for face-to-face additional time spent with the patient in the office or hospital, and one set for non-face-to-face time. Non-face-to-face time is typically not paid by most insurers. In 2009, CPT® changes its description of these...Can a Physicians Assistant do a consult?March 9th, 2009 - Codapedia Editor
This question comes up at seminar after seminar. Someone says, "My billing manager told me that PAs (or NPs) can't do consults. Is that true?" It is a half truth.
PAs and NPs may perform consults, as long as consults are in their state scope of practice. They may perform consults on...Do you need three vital signs for it to count?March 4th, 2009 - Codapedia Editor
This is one of the most common questions physicians and NPPs ask at coding conferences. Do I need to document three vital signs for it to count.
It depends on which set of guidelines the clinician is using.
For 1995, no. Any one vital sign or general appearance counts for constitutional.
For...Comprehensive exam, 1995 GiudelinesMarch 4th, 2009 - Codapedia Editor
A comprehensive exam using the 1995 Guidelines requires eight organ systems. You may not count body areas. The Guidelines do not give any definition about how much must be examined in each system, and auditors typically count anything within that system. The Guidelines say,
Comprehensive -- a...Anticoagulant managementMarch 3rd, 2009 - Codapedia Editor
In 2007, CPT® added two codes for anticoagulant management, 99363 and 99364. The codes are meant to be used by physicians and Non-Physician Practitioners (NPPs) who manage a patient's warfarin therapy on an outpatient basis, reviewing the PTINR, adjusting the patient's dosage as appropriate,...Consults in a groupFebruary 23rd, 2009 - Codapedia Editor
Can one physician request a consult from another physician in the same group?
Sometimes. (Don't we long for yes or no answers?)
One physician can request a consult from another physician in the same group, of the same or different specialty, when the conditions of a consult are met, and the...Hospitalist ServicesFebruary 12th, 2009 - Codapedia Editor
Hospitals are adding hospitalist services at a fast pace. Everyone is recruiting for hospitalists. It's changed the face of primary care. Primary care physicians are now in their offices more hours of the day. Their hospitalized patients are cared for by a group of physicians without office...Observation dischargeFebruary 12th, 2009 - Codapedia Editor
There is only one code for observation day discharge management, 99217. Unlike discharge day management from inpatient status or nursing homes, there are not two levels based on time. Use 99217 no matter how long the discharge takes.
The patient status must be Observation status to use this...Hospital Discharge Day ServicesFebruary 12th, 2009 - Codapedia Editor
Use codes 99238 or 99239 for services provided to a patient being discharged from inpatient status in the hospital. These codes include all of the work performed on the calendar day to discharge a patient, including the exam, discussion with the patient and caregivers, and discharge paperwork. ...Auditing the exam 1995 GuidelinesFebruary 11th, 2009 - Codapedia Editor
Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. ...Mandated visits in a nursing facilityFebruary 11th, 2009 - Codapedia Editor
What are mandated nursing home visits and who mandates them? May either a physician or qualified Non-Physician Practitioner (NPP) perform these?
CMS mandates that residents in nursing homes be assessed by a physician or NPP at periodic intervals. This is a requirement for the nursing home's...Physicians in a GroupFebruary 9th, 2009 - Codapedia Editor
Medicare and other third party payers pay have specific rules for paying physicians of the same specialty in a group. Here is what the Medicare Claims Processing Manual says:
30.6.5 - Physicians in Group Practice
(Rev. 1, 10-01-03)
Physicians in the same group practice who are in the same...Interval HistoryFebruary 9th, 2009 - Codapedia Editor
Some CPT® codes require an interval history. This article defines an interval history.Are two E/M services payable on the same day?February 9th, 2009 - Codapedia Editor
There are times when physicians or NPPs see a patient twice in a single day, and want to know if both are reportable, and if both are paid by insurances or Medicare. In general, only one service is paid, but there are some instances in which both can be paid.E/M ProfilesJanuary 29th, 2009 - Codapedia Editor
CMS and other payers collect data on the utilization of E/M services within each category of service. For example, for all of the established patient visits billed using codes 99211 to 99215 by Rheumatologists, CMS keeps track of what percentage are level one’s, level two’s, level...Consultation servicesJanuary 29th, 2009 - Codapedia Editor
Let’s start with Medicare’s definition of a consultation
Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.10A
Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code...Critical Care and the Teaching Physician RulesJanuary 29th, 2009 - Codapedia Editor
Only the time of the teaching physician--not the resident--may be reported as critical care time. That's the short answer.
Review the articles in Codapedia related to the requirements for critical care billing and critical care to neonates and pediatric patients.
Only the attending physician...Critical careJanuary 29th, 2009 - Codapedia Editor
Critical care services are services provided to a critically ill patient. It sounds like a circular definition.doesn't it? The first requirement for billing critical care is the status or condition of the patient. Although critical care services are often provided in a criticla care unit,...Welcome to Medicare VisitJanuary 29th, 2009 - Codapedia Editor
Welcome to Medicare
Initial Preventive Physical Examination (IPPE)
A new benefit under the Medicare Modernization Act
Effective date 1-1-05, changes for 2009
Eligibility: Any Medicare beneficiary who enrolls in Medicare on or after January 1, 2005
Time limits: Eligible for benefit in the...ConsultationsJanuary 28th, 2009 - Codapedia Editor
CPT® defines two sets of consultation codes: outpatient/office consults using 99241 through 99245 and inpatient/nursing facility consults using codes 99251 through 99255.
The Center for Medicaid and Medicare Services (CMS) defines a consult in this way
Specifically, a consultation service is...