Q We are a group of five pediatricians. All of us personally do the parent counseling prior to immunizations and clinically screen the patient before proceeding with immunizations. We answer all their questions and discuss the vaccine information statement. We have received conflicting advice on billing for physician services from various sources, from using 99211 (the so-called nurse’s code), to 90212, to nothing if we are using 90465-90468. (We do spend about five to eight minutes to counsel, screen face to face, and answer parents’ questions and concerns.) Please help.
A You have given the answer in your question. If you are administering vaccines that day, and the child is younger than 8 years old, then your counseling is included in the administration codes 90465-90468. You should do nothing (else) for reporting of the counseling itself.
The CPT manual states that “if a significant separately identifiable E&M service (e.g. office or other outpatient services, preventive medicine services) is performed, the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.”
What they are most likely referring to is the well visit, or developmental visit of which vaccines are so often a part. There could also be another problem, illness, or injury that was being evaluated or managed on the same day as vaccine administration. This would be reported with an E&M code as well, along with the diagnosis for the other problem.
But if someone is suggesting that you bill either a 99211 or a 99212 — over and above the 90465-90468 codes — to represent the vaccine counseling, then they are steering you in troubled waters.
New or Established?
Q What do you say to those new patients scheduled for preventive medicine, who then wind up having an “oh by the way, I have this problem today” visit? In this instance, the provider would report a preventive code; would it be NP E&M or EST E&M?
I know all efforts should be made to bring the patient in as new to get established, but that does not always happen in a perfect world, and the provider wants to give good customer service. Your thoughts?
A You have some options there really. It kind of comes down to semantics. If I understand correctly, the patient presents for a preventive service, so you will be billing 99381-99387. The real question is whether the additional E&M is new or established.
The definition of new patient on page 1 of CPT describes someone who has not received any services from the physician in the last three years. Well, doesn’t the last three years include the last twenty minutes?
I had a Medicare medical director once say to me in response to that: “But how can a patient be new and established the same day?” I think it’s clear. I also realize it seems like a contradiction in terms, but as I said, you aren’t technically new anymore after having received the preventive services.
I have no doubt this will disturb some people. Some payers do pay the combination new preventive/established office. Others deny it. You would think payers would want to see it my way — it’s cheaper for them.
When you look at the work that goes into handling a problem, after you have just done a comprehensive Hx and PE, the additional work likely consists of a bit of HPI, maybe some additional PE and the A/P portion. There is significant overlap in coding both a new preventive and the new medical management code. There is in fact some economy of scale when performing them together — you really aren’t doing all of both codes. For that reason, the RVUs for the total work done are more consistent with a new preventive/established problem visit. Those are my thoughts anyway. Good luck.
Coding for Coordinating Care
Q Which codes should I use for medication monitoring, reviewing test results, or coordinating medical care?
A The general answer is that these sound like E&M services, so depending on the site of service (sounds like office) you’d use the appropriate E&M category codes. But your question has three parts really, and I’d like to take them one by one.
When you say medication monitoring, this could take the form of a regular office visit. Get some screening labs a few days prior and have the patient come in to query him or her about signs and symptoms. This is chronic disease follow-up — a perfect application for established E&M codes.
If the patient is in a rest home, nursing home, hospice, or receiving home healthcare — and you spend a certain amount of time each month in contact with caregivers and surrogates discussing medication management by phone, fax, or other — you may want to check out the Care Plan Oversight codes in the E&M chapter of CPT. You have to spend a minimum of 15 minutes a month providing some type of remote management, and document it — but that’s another possible way to get at medication management.
Clinical lab tests in the CPT book have no professional component. In other words, there is no work associated with interpreting them built into the codes. When you bill for those, you are billing the technical service of performing the test.
Credit for the work of interpreting labs is part of the calculation of the decision-making component of an E&M code. See the last page of the E&M section guidance in CPT for details on this.
And the third item, coordinating care, could fall under the Care Plan Oversight codes as discussed above. It could also entitle you to bill a regular E&M by time. Again, lot’s of information here in the CPT manual. Read pages one through eight and you’ll learn a lot!
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.
This article originally appeared in the October 2009 issue of Physicians Practice.
