Primary care exception

Q I work in a residency setting and we use the primary care exception rule that lets residents bill up to level three without attending physician presence. Two questions: 1) How do we bill inpatient services with the GE modifier using the exception, and 2) Can we use the exception on preventive services like 99397?

A As to the inpatient service portion of your question, the exception rule states that “the services must be furnished in a primary-care center located in the outpatient department of a hospital or another ambulatory care entity.” So no, there is no case where you would use GE for an inpatient service, only GC. If residents are involved in inpatient care, the attending must meet the presence requirements and document it. If a resident sees the patient without attending presence, it is not a billable service.

The second question involves preventive services. According to the CMS guidelines: “Medicare may grant a primary care exception within an approved GME program in which the teaching physician is paid for certain E&M services the resident performs when the teaching physician is not present. The primary care exception applies to the following lower- and mid-level E&M services: 99201, 99202, 99203, 99211, 99212, 99213.

Effective January 1, 2005, the following code is included under the primary exception: Healthcare Common Procedure Coding System code G3044: Initial Preventive Physical Examination: face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment.”

The rules here pretty clearly define which codes can and can’t be used. That last sentence says “code” — singular. I’m interpreting that to mean the other preventive service codes 99381-99397 are not eligible for the exception. That does not mean they can’t be provided by a combination of resident and attending physicians and billed with a GC.

Critical care code

Q Can I bill a critical care code if a patient becomes seriously ill while in my office?

A Yes, you just have to meet the requirements for critical care, which is a timed code. The reason we don’t see much of it in the office is that the minimum time for reporting a critical care service is 30 minutes — and usually, the patient is transported elsewhere by then when they become critically ill in the office.

The CPT manual defines it as “direct delivery of medical care for a critically ill or injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” There are no site-of-service restrictions.

Prescription drug management

Q My coder tells me that when I use a prescription medication on a new problem that I automatically qualify for moderate level decision making. I’m a pediatrician, and for me this fits a lot of what I feel are lower level problems. Am I under-coding my services if I bill 99213 with some prescriptive management?

A Not necessarily. Your coder is referencing the decision-making tables that Medicare and other payers may use to determine the level of medical decision making. Technically he or she is correct, but that may not save you in a medical necessity review. Your instinct seems to me to be much more in tune with medical necessity.

One of the three tables gives points for the number of problems dealt with: one point for each established stable problem, two points for a worsening established problem, and three points for a new problem. We talked about these in the last issue. There is no issue with a new problem getting you three points, or moderate complexity, in this table.

The sticky point is the part about writing for a prescription medication. Your coder is correct that the entry “prescription drug management” is listed in the “moderate” section. But using this to determine the level of risk is interpreting the table somewhat mechanically, seemingly without a good grasp of medical necessity.

The mere presence of prescription drugs does not necessarily qualify for moderate complexity. CMS has indicated that writing a prescription for a seven- or 10-day supply of an antibiotic is not considered to be a moderate level of complexity. At least one Blue Cross company has indicated that prescription drug management involves more than the use of prescription drugs. It may mean a change in regimen, the addition of an agent, or the worsening of a problem. In other words, any prescription is not a guarantee that a payer will see this your way.

Consider the entry in the first column of the table, Presenting Problem, under low level decision making. It says “acute uncomplicated illness or injury; e.g., cystitis, allergic rhinitis, simple sprain.” Does the new problem that you were describing fit into this category? If so, you might be more accurate — as you indicated — with the low level decision making associated with a 99213.

I’m not trying to diminish your work in any way. I am only saying that a medical necessity review may find the problem more of a low level one, despite the fact that a prescription was written. Remember that those tables were in use as far back as 1990 — almost 20 years ago. The ink may not have changed on the page, but the interpretation may have moved away from the literal.

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 billdacey@msn.com .

This article originally appeared in the January 2010 issue of Physicians Practice.