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Coding Questions?
Surgical package; billing family members; using 99211 for new patients
By Bill Dacey

Surgical Package?

Q What exactly is included in the surgical package?

A The CPT manual tells you everything the AMA considers to be always included in a surgical code where the package applies. They are:

Local infiltration, metacarpal/metatarsal, digital block, or local anesthesia

Subsequent to the decision for surgery, one related E&M visit on the date immediately prior to or on the date of the procedure

Immediate postoperative care, orders

Typical postoperative follow-up care

Some of the services above — the E&M before the surgery, for example — are not included in packages with a zero-day global period. In fact what is included varies by payer, and the whole “package” concept is now better viewed as a function of CCI edits and a given payer’s reimbursement policy.

The services listed below are typically not part of a package:

Initial decision for surgery

Services by other providers (different specialty or group)

Visits unrelated to the surgical diagnosis (modifier 24)

Treatment for underlying conditions

Staged/related/distinct procedures (modifier 58/59)

Complications following surgery (modifier 78)

Unrelated surgical procedures (modifier 79)

Medicare has a slightly different version of what is included in a given package: “All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications which do not require additional trips to the operating room.”

Primary-care providers most often deal with procedures of the office or bedside variety. These usually have zero- or 10-day global periods. If in doubt, bill for what you do. If someone thinks it is bundled or part of the global, you’ll find out!

Billing Family Members

Q I read that it was OK to bill a family member for appointments to discuss patients. Is it acceptable to bill the family members/caregivers on a cash basis as long as we notify them ahead of time? Would you recommend that we base the fee on the E&M codes? Should the appointment be made under the patient’s name? I don’t know if this would make a difference if we were to get audited.

A It is acceptable to bill the family member. And it’s better with advance notice, as you point out. Remember, part of the description for E&M codes in the AMA’s CPT manual says counseling with “patient and/or family or caregiver.” Only Medicare, that I know of, specifies that the patient be present. And who is going to audit a self-pay account? I don’t think it matters whose name the appointment is in — you are going out of your way to be compliant.

99211 for New Patients?

Q Can we use 99211 with new patients?

A I want to say no. That was not the intent of that code. It is clearly in the established subcategory of CPT. Why do you want to use it with new patients? For new patient visits where the physician does not see the patient?

If you are looking for a code where the physician does not see the patient, to represent some lower-level encounter, then you may have the right code, but there are potential consequences.

No payer would likely deny you if you bill an established patient code the first time you see a patient — but they might deny a subsequent visit billed as a new patient encounter. And you can see why they would.

However, the CPT book does state that a professional service is defined as a “face-to-face” encounter between a physician and a patient. In the absence of a face-to-face encounter you could make the case that a 99211 was the best available code in the overall category. But since it says “established” in the description — and if you take payment for that code — you most likely have lost any claim to “new” patient following this.

It’s really not the right code, but I don’t think anyone will stop you from using it.

But be careful here. There has always been a considerable amount of abuse with code 99211. Be certain that there is a documented amount of physician work associated with any use of this code. Although commonly referred to as a “nurse visit,” this code only states that the presence of a physician “may” not be required.

These codes are reported with the physician’s provider number, so the suggestion is that there is physician work involved. Though there are no written documentation requirements or specific performance standards for 99211, common sense dictates that the physician make a note, albeit brief, concerning his/her involvement.

These codes are primarily used to report visits where some clinically significant information is obtained, often by a nurse, such as weight, blood pressure, or even a blood draw for periodic surveillance of a problem (such as lipids). That information is then recorded in the chart for physician review, and when it is reviewed by the physician, a notation should be made indicating the disposition, such as “leave meds as they are” or “call the patient.” This code is never to be used in the absence of a patient visit.

Coding of Immunizations

Q In the 2009 CPT book, under preventive medicine services, they have removed the language “(ordering of) appropriate immunization(s).” What does that mean for coding of immunizations?

A That means that you should code for the administration of immunizations as well as the supply. The preventive code language was intended to portray the types of cognitive services involved with health maintenance. The language came to be confused with the actual provision of the service. Use the administration codes 90465 to 90474 for the service of administering vaccines. Use also the codes 90476 to 90749 for the supply itself.

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 18 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This article originally appeared in the September 2009 issue of Physicians Practice.

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