DAVID STERN, MD (Practice Velocity) Q.Our urgent care practice serves a 70-physician primary care group. The UC uses the three-year rule; if the patient has been seen by any physician in the medical group within the last three years, he/she is an established patient even if the patient has never been previously seen in the urgent care. A comparable UC center in a nearby city applies the three-year rule differently; if the patient has been …
Read MoreReaders’ Coding Inquiries
DAVID STERN, MD (Practice Velocity) Q.How would you define the difference between an expanded problem-focused exam and the detailed exam in the 1995 evaluation and management coding guidelines? – Question submitted by Eddie Stahl, Medical Staff Director, Tennessee Urgent Care Associates A.For both the expanded problem-focused exam (EPF) and the detailed exam, the provider must document between two and seven body systems. The difference is that the EPF exam requires a “limited” exam of a …
Read MoreDeciphering Payor Language and Other Challenges
DAVID STERN, MD (Practice Velocity) Q.Many procedures, such as injections and fracture care, are reported to patients as “surgery.” Patients sometimes accuse us of false billing, as they don’t consider these procedures to be a “surgery.” How can we fix this problem? A.All third-party payors have installed computer software programs that have code descriptions loaded for each CPT code. Many of these code descriptions are hard to understand, and sometimes they are not truly accurate. CPT …
Read MoreFollow-up Questions Regarding Post – operative Care and ‘Established’ Patients
DAVID STERN, MD (Practice Velocity) Q.I was curious about your response to a case listed in Coding Q&A in the November issue of JUCM. The case described a patient who returned for reopening of a wound due to infection. The physician then cleansed and re-sutured the wound. Although I agree about the postoperative care in general, I wonder if modifier -79 would be appropriate in these circumstances. According to instructions by the AMA, this modifier …
Read MoreProper Coding for Removal of Foreign Bodies
Q.Recently we removed a tampon that was retained for one week. What is the code for removing a foreign body from the vagina? A.Although this procedure involves significant work, and the resultant foul odor can leave an exam room unusable for hours, the procedure is considered to be a part of the E/M. Of course, this is hard to understand, since there is a code for removing a foreign body from the external ear canal …
Read MoreCoding for Removal of Impacted Cerumen (69210)
Q.What is the correct use of CPT code 69210 (removal impacted cerumen [separate procedure], one or both ears)? – Question submitted by Kathy Partenheimer, Medical of Dubois A.In the July 2005 issue of CPT Assistant, the AMA clearly indicates that you should report 69210 onlywhen the following two criteria are both met: “the patient had cerumen impaction” “the removal required physician work using at least an otoscope and instrumentation rather than simple lavage” [emphasis added]. …
Read MoreInjection Procedures and E/M Codes
DAVID STERN, MD (Practice Velocity) Q.Can we bill an evaluation and management code along with the code for administration of an intravenous injection? A.Although it may seem obvious to expect reimbursement in these situations, Medicare waited until 2006 to begin reimbursing physicians for a separate E/M (99201- 99205, 99212-99215) when performed at the same time as IV drug administration. The Medicare Claims Processing Manual states, “Medicare will pay for medically necessary office/outpatient visits billed on …
Read MoreAdditional Income from After-Hours Codes (99050, 99051, 99053)
DAVID STERN, MD (Practice Velocity) Q.A patient with a finger laceration walked into our urgent care center at 8:05 p.m., five minutes after our closing time. Rather than turn the patient away, our team decided to care for the patient. Three of our staff, including the physician, stayed for 50 minutes after our posted closing time. If we had not stayed after our scheduled closing time, the patient would have been forced to go to …
Read MoreHow to Use the Level 1 Established Patient E/M Code (99211)
DAVID STERN, MD (Practice Velocity) Q.What is the code 99211? A.The official description is as follows: “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, five minutes are spent performing or supervising these services.” This is a low-level Evaluation and Management (E/M) service. The code requires a face-to-face patient encounter with a staff member …
Read MoreCode Compliantly But Differently, Based on the Payor
DAVID STERN, MD (Practice Velocity) Q.I have been told that I can get credit for a complete review of systems (at least 10 systems) by simply noting positive findings in certain systems and then noting “all other systems negative.” A.This is, indeed, a general CMS “guideline,” but two Medicare carriers have issued contradictory guidelines. TrailBlazer Health Enterprises (Medicare carrier for Delaware, the District of Columbia, Maryland, Virginia, and Texas) and Wisconsin Physicians Services (Medicare carrier …
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