Q. When a patient comes in with ear pain due to impacted cerumen, the health-care provider would normally instruct the nurse to perform ear irrigation. If the irrigation successfully removed the impacted cerumen, the procedure would be considered part of any evaluation and management (E/M) service and we could not bill for the service separately. With new rules regarding cerumen removal this year, can we get reimbursed for the ear irrigation if it is not …
Read MoreFracture Care
Q. Will you please help me understand initial visit, subsequent visit, and sequelae related to fracture care? If the patient is treated elsewhere for a fracture and the provider just stabilizes the fracture and instructs the patient to then come to my office for reduction, is this a subsequent visit or an initial visit? A. International Classification of Diseases 10th Revision, ClinicalModification (ICD-10-CM) guidelines state that a seventh character, A, is used for the initial …
Read MoreProlonged-Service Codes
Q. The coding staff has relayed to me that we can now bill for times when my clinical staff must spend extra time with a patient. Is this true? What are the requirements for documentation? A. Yes, two new Current Procedural Terminology (CPT) codes added in 2016 by the American Medical Association allow you to bill for clinical staff members’ time spent with a patient above and beyond what is considered to be the usual amount of time. …
Read MoreExcludes Notations and Code Notes
Q. How do I use Excludes 1 and Excludes 2 instructions in International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM)? A. Put simply, the Excludes 1 notation means that you cannot code any excluded code with the main (listed) code. Conditions listed with Excludes 1 are mutually exclusive. For example, code E11 (type 2 diabetes mellitus) has an Excludes 1 notation with the following codes listed: Diabetes mellitus due to underlying condition (E08.-) Drug …
Read More2016 Current Procedural Terminology Changes Pertinent to Urgent Care
Evaluation and Management There were two revisions and two additions to the “Evaluation and Management” section. Add-on codes 99354, “Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour,” and 99355, “. . . each additional 30 minutes,” were revised to add the term psychotherapy in the description. Some good news in …
Read MoreSame or Similar Diagnoses for Follow-Up Visits
Q. Is there a global period for the diagnosis used for follow-up on an evaluation and management (E/M) code when there is not a change in the chief symptom? We had a patient with a skin irritation for which the provider prescribed a hydrocortisone cream for the diagnosis of “dermatitis, unspecified” (L30.9). The provider instructed the patient to return in 1 week if the condition did not clear up. The patient returned 3 days later …
Read MoreUnspecified Diagnosis Codes, Preoperative Examinations, and Tuberculosis Skin Tests
Q. We are afraid of getting denials for using unspecified ICD-10-CM [International Classification of Diseases, 10th Revision, Clinical Modification] codes. In an urgent care center, we sometimes will see a particular patient only one time for minor illnesses and injuries, and follow-up with their primary-care physician is always advised. Do you have any advice on documenting to get claims paid? A. Within ICD-10-CM, you may select codes defined as “Not Otherwise Specified” (NOS). Generally, this should …
Read MoreTravel Immunizations
Q. What is the best way to code for and bill patients who come in because they are planning to travel out of the country and need to know what immunizations they should have before traveling? We advise them on preventive measures to take in relation to where they are traveling, provide literature if appropriate, and even try to find health-care facilities close to where they will be staying while abroad. I know we can …
Read MoreOpen Fracture Treatment Versus Closed Fracture Treatment
Q. We had a patient come in with an open fracture of the distal interphalangeal joint of the right index and middle fingers, ICD-9 [International Classification of Diseases, 9th Revision, Clinical Modification] code 816.12. The provider set and splinted them both. Can I bill procedure code 26765 (“Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each”) twice? A. A diagnosis of open fracture means that the skin has been …
Read MoreElectrocardiogram Data Points and Evaluation and Management Visit Level; Gait Training
Q. When counting data points for the complexity of medical decision-making (CMDM) portion of the evaluation and management (E/M) visit level, what is the correct way to assign data points for an electrocardiogram? For example, the Current Procedural Terminology (CPT) code is 71020 for a chest radiograph with interpretation and report. The description itself has the interpretation and analysis included in the code already. Is it considered double-dipping if we count the interpretation as 1 …
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