Emily Hill

Can you please tell me which ICD-9 code is correct for a patient that has a history of myocardial infarction?

 ICD-9 412 is described as "old myocardial infarctions." The inclusion notes state "healed myocardial infarction" and "past myocardial infarction diagnosed on ECG or other special investigation, but currently not presenting symptoms." The codes in the V section that describe personal history of diseases specifically exclude old myocardial infarction (see V12.5).

I have never understood why insurance companies reimburse the same global fee for vaginal deliveries and C-sections. Intra-abdominal surgery, including C-sections, requires special training in surgical techniques and carries with it more risks and time spent with the patient. Why then, is it not compensated as such? Is there any way to get increased compensation?

 According to fee schedule surveys done by Physicians Practice, payers usually do pay more for C-sections (about $2,295) than vaginal deliveries (about $1,926). That is not a huge difference, but it's something.

To get that additional money, first make sure you are using the right codes:

59510 for antepartum, C-section and postpartum care

59618 for antepartum, C-section and postpartum care following attempted vaginal delivery after previous C-section

59400 for antepartum, vaginal delivery, and postpartum care

For truly unusual circumstances, you also can add the -22 modifier -- unusual procedural services -- indicating that you provided a greater than usual service, and back it up with strong ICD-9 coding and proof of medical necessity.

If you are being paid exactly the same for surgical and non surgical births and are coding correctly, review your payer contracts. If you are paid a percentage of Medicare payments for all services, then you should contact the payer. In the 2005 Medicare fee schedule, C-sections have total RVUs of 49.62 versus vaginal deliveries at 43.78. Sometimes, obstetrical care is paid under a different formula. Check your contract carefully.

A patient visits to discuss multiple problems and data. At the end of the appointment, the patient wants to discuss a couple more problems that may or may not require a redirected examination. Can I bill a second CPT with modifier?

 You are unlikely to get paid for two office visits on the same date of service -- especially since what you describe really is just one office visit that turned out to be more complex than expected.

You could take either of these approaches:

Address the additional issues there and then but be sure to account for the added complexity of the visit when you select an E&M code. You might be able to code a 99214 versus a 99212, for example. Code according to what you did, not what was scheduled. Of course, any procedures done in addition to the office visit could be coded separately with a modifier.

Ask the patient to schedule another appointment to discuss the additional issues. This is a tough balance to strike. You don't want to inconvenience a patient who is sitting right in front of you, and you certainly shouldn't postpone care that has immediate implications. However, you also don't want to put yourself way behind schedule, frustrating patients in the waiting room.

I'm an independent physician with my own practice. If I perform a service on an inpatient in the hospital, do I bill the nonfacility or the facility fee that is in the Medicare fee schedule? 

 The place of service (POS) code you submit on your claim form determines which fee schedule is utilized for reimbursement, not necessarily what you charge. Most physicians have a single fee schedule that is not related to where the service is provided. You simply submit the codes along with your established fee. The POS code tells Medicare what to pay. However, if you want to track the accuracy of those payments, services rendered in the hospital should reflect the facility payment. Nonfacility payments are made for office-based services.

What is the correct code for wide, local excision of a melanoma on the arm? Is it coded as a malignant skin lesion by size or as a removal of arm mass?

 The proper code depends on the depth of the lesion or mass. The codes in CPT for lesion removal define excision as full-thickness (through the dermis) removal of a lesion including margins, plus simple closure when performed. The proper excision code is determined by measuring the lesion diameter plus the most narrow margins required for complete excision. The codes for excision of soft tissue masses indicate involvement in subcutaneous tissue or the subfascial or intramuscular areas.

We have a purchased service agreement to bill MRIs/CTs done outside our office. We bill globally for commercial payers. What would be the place of service (POS)? Right now we are billing time of service (TOS) -- diagnostic X-ray and POS office -- even though the service is not performed in our office.

 It is somewhat difficult to assign an actual POS code since you do not specify the exact location where the service is being provided. If these services are being provided by a mobile unit, use POS code 15. The POS code for an outpatient clinic is code 49 while outpatient hospital is code 22.

The POS codes are maintained by CMS and are available on the Medicare Web site. It is always best to check with your individual payer to determine what code(s) are recognized for reimbursement.

How do I code for a Pap smear conducted the same day as an annual exam?

 Usually, the collection of a Pap smear is included in a well-woman exam or other evaluation and management service so you can't really code or bill for it. Your compensation is included in your compensation for the well-woman or office visit code.

But that is just true of collecting the specimen.

One can code for interpretation of the Pap smear, if it's covered by the payer, but most practices send such samples to labs that do the interpretation and bill for it themselves.

Medicare does reimburse separately for the collection of a screening Pap smear reported with HCPCS Q0091. It cannot be reported for the collection of a diagnostic Pap smear.

I am in a multispecialty group practice and sometimes ask my colleagues in other specialties for a consult. Can the consulting physician bill for the visit? Even if we share a group ID number?

 The consulting physician should be able to bill and collect. If the requirements for a consultation code are met, the physician may report a consultation code even though the requesting physician is in the same group practice. In general, the problem must be outside the area of expertise of the requesting physician. Most payers, including Medicare, will verify that the physicians are of different specialties or subspecialties as a means to evaluate that particular criteria.


The deciding factor may not be whether you are in the same group. What matters is whether you've followed all the rules for billing a consult.

the service involves rendering a specific opinion or advice at the request of another physician or other appropriate source;

the request and the need for a consultation is documented in the patient's medical record; and

the consultant provides a written report of his or her findings to the referring physician.

If these criteria are not met, then the receiving physician reports a new or established patient visit instead.

We sometimes see children with behavioral problems. They don't have a defined psychological diagnosis but are just acting out and the mother wants some advice. How should we code for these visits? We don't want to use a psychiatric diagnosis code; none seems right. 

 Typically, payers expect you to use V codes to report reasons for healthcare encounters other than identified illness, injury, or condition. There may be some codes in the V section that would be appropriate for these patients. You might also look in the 780-799 section of ICD. This section lists signs and symptoms that can be used when a definitive diagnosis has not been determined.

When a patient comes for a "get established" visit with no serious complaints, we are coding as an annual exam. Are there separate procedure charges for the breast exam, prostate exam, etc.? Or are these global in the E&M code? If so, should modifier -25 be used anywhere?

 There is no CPT code for a "get acquainted" visit, so you'll need to perform a true well-male or well-female check in order to bill for these. If you are, the likelihood is that all of the services (e.g., DRE) are indeed included in the E&M. Diagnostic tests and immunizations are reported separately. Most payers do not require the -25 modifier on the E/M service when billed in conjunction with diagnostic tests.

Emily Hill, PA-C, president of Hill & Associates Inc., has 14 years of experience as a healthcare consultant. She has worked with numerous academic and private practices on coding, reimbursement, compliance, and practice management issues. She currently serves as a representative on the American Medical Association's Correct Coding Policy Committee, the Health Care Professionals Advisory Committee Review Board for the Relative Value Update Committee (RUC), and the National Uniform Claim Committee. She can be reached at 

This article originally appeared in the September 2005 issue of

Articles

Here is some medical coding guidance on diagnosis code for history of MI; better pay for C-sections; billing facility versus nonfacility fees; and much more.

Your Toughest Medical Coding Problems Solved


Q: I noticed that the J-code for lidocaine J2000 is deleted from my HCPCS book. Is there a code for this?

A: In January 2004, Medicare stated that it would no longer pay separately for a lidocaine injection used to numb an area prior to a therapeutic injection; therefore J2000 was deleted from the HCPCS manual. Medicare pays for the therapeutic injection code (20600-20610) only. The local anesthetic is bundled into the main procedure. This is consistent with CPT instructions.


Q: What is the CPT code for paravertebral facet injection without fluoroscopy?

A: The CPT codes for these services are in the 64470-64476 range. The codes are based on the location (cervical/thoracic or lumbar/sacral) and the number of levels injected. These codes do not include the use of fluoroscopy. The CPT notes preceding the codes state that the use of fluoroscopy should be reported separately using code 76005. 


Q: Can we bill for a phenergan 12.5 mg suppository if we administer it in our office? I see that there is a 2005 J code for an IV, but not for suppositories.

A: The administration of a phenergan suppository is considered a part of the E&M encounter and cannot be billed separately.


Q: I started using Denver 2 for developmental screening for all kids who come in for a routine checkup. I use CPT 96110, but not I'm not sure what ICD code to use. Some have suggested using 783.40, but I don't feel comfortable with it. Most of these kids are in the normal range. Is there a code for just a developmental screen?

A: Since this is a routine screening you should probably use V20.2, routine infant or child health check, which covers developmental testing of an infant or child. If there are any problems indicated, you would use the V codes that identify special screening for developmental handicaps (V79.3).


Q: If we see a child in the office and give a nebulizer treatment and/or perform tests, and then later admit the child to the hospital, can we bill for the treatment and tests? We know we can't bill for an E&M visit.

A: While you cannot bill for the E&M visit, you can bill for any treatments or tests performed in the office prior to admitting the child to the hospital.


Q: What should I do if there is simply no appropriate diagnosis code to meet my patient's circumstances?

A: If there is no diagnosis code available, you can use "unspecified diagnosis." This code is typically at the end of each section of diagnoses in the ICD-9 manual, so try to use the unspecified code that at least relates to the general category of diagnoses at hand. 

Depending on the carrier, a claim with an unspecified code may automatically be rejected. Have an appeal letter and the office or operative notes ready to attach to your resubmission.


Q: As a primary-care physician, can I submit an office consult on one of my own patients when I have been sent a consult request from a surgeon for a preoperative clearance? 

A: Yes, Medicare clarified this several years ago: a physician may report a consultation code for a preoperative clearance if all the requirements of a consult are met - that is, the consult was requested by another provider for a specific indication and a written report is supplied to the requesting provider. The consultation code can be reported even for an encounter with an established patient.


Q: When billing for the delivery of several vaccines, using CPT 90472, should we bill each one individually linked to each diagnosis or is it better to bill the total units?


A: In general, it may be helpful to list each separately with each different diagnosis code. This might keep the payer from denying all but one administration code if the system only picks up the first diagnosis.


Q: If a patient is in a 23-hour hold for observation, then is admitted, wouldn't the observation be disregarded for billing purposes?

A: It depends on the dates of service for the initiation of observation and the hospital admission. If the patient was "admitted" to observation and to inpatient status on the same date, only the hospital admission code is reported. If initiation of observation occurred on a different date than the admission, you can report both services.

The documentation for both the observation and the hospital admission codes must support the level of service billed. If the physician documents less than the requirements for a hospital admission, you can report a subsequent hospital care code instead.


Q: How do we bill for a well visit when the patient also presented a sick complaint?

A: If a patient has received services for both preventive and problem-oriented care on the same day, then you can report both codes with the -25 modifier appended to the problem-oriented E&M service.

It is not appropriate to report preventive medicine visits under a problem-oriented code, nor is it correct to increase the level of service to account for the preventive portion of the encounter. Be sure that the diagnosis for the problem is linked to the problem-oriented E&M service on the claim form.


Q: One of our specialists performed an initial consult on a new patient. A few weeks later, the patient came back, this time in need of a consult for a new problem. Is the second visit a follow-up consult or a second initial consult? A: CPT specifically states, "If an additional request for an opinion or advice regarding ...  a new problem is received from the attending physician and documented in the medical record, the consultation codes may be used again." There are no follow-up outpatient consultation codes. In the outpatient setting, the physician would simply report another outpatient consultation code.

For inpatient consultations, "only one initial consultation should be reported by a consultant per admission." Thus, your physician can use a consult code, but not an initial one if the requests occurred during the same hospitalization. She must use a follow-up consultation code or a subsequent hospital care code. If the requests were made during different hospitalizations, then an initial inpatient consultation code can be reported for both encounters. If the physician assumes any portion of the care of the patient following the first encounter, subsequent services are not reported using consultation codes.

This article originally appeared in the July/August 2005 issue of 

Here is medical coding guidance on lidocaine injection; vertebral injection; phenergan suppositories; Denver 2 screening; treatment before admission; and more.

Coding Questions?

Q: If psychological testing is conducted by a physician during a psychiatrist office visit is there a specific code that can be used? Does Medicaid pay for this?

A: There are CPT codes for psychological testing that are reported per hour and require a formal interpretation and written report. Code 96100 is for psychological testing and code 96117 is for a neuropsychological testing battery. Other codes to describe testing of cognitive function are found in the section of CPT (96100-96117). Since Medicaid policies vary from state to state, you should check with your particular Medicaid program regarding its policies for reimbursement of these services.

Q: We have been billing Medicare the technical portion of X-rays that are done at our site (and ordered by myself) under my Medicare provider number. I am not a radiologist, the technician is not my employee (she is a hospital employee); I do not supervise the X-ray techs, nor do I examine the X-rays for quality. The hospital radiologists read all the films and bill for the professional component. Is this a concern?

A: The answer, in part, depends on who owns the actual X-ray equipment and if you have costs associated with the technician. If the equipment and supplies are yours, you can bill for the technical portion of the X-rays. If they are the hospital's, you can't -- it's their resources that are being used.  

Q: If a patient dies the same day I've seen him in the hospital, can I bill for physician services? 

A: If the physician sees the patient on the date of death, the physician can report an inpatient E&M code such as 99231-99233. If the patient dies before the physician has seen him, it is appropriate to report a discharge management code for pronouncing the death, completion of discharge summary, etc. 

Q: I cut a lingular frenulum (tongue tied) on a newborn and am not sure how to bill for this. Should it be added as a modifier if it was done during a well-child check -- and what would be an appropriate fee? 

A: Code 41010 describes a lingual frenotomy and seems to match the service you described. It has 4.56 RVUs so you might base your fee on a similarly valued service already in your fee schedule. The procedure has a 10-day global period under the RBRVS system so a follow-up visit during that timeframe should not be reported separately. If it is done at the time of an E&M service such as a well-child check, append the -25 modifier to the visit code.


Q: Our practice has submitted G0001 for Medicare venipuncture and has been denied for all 2005 charges. The EOBs say, "Payment denied, procedure code invalid for date of service of claims submission." Is there a new code for Medicare venipuncture or are they now nonpayable?

A: Effective January 1, 2005, G0001 -- routine venipuncture for specimen(s) collection has been deleted. Use CPT 36415 --collection of venous blood by venipuncture to bill Medicare for these services.

Q: Can a surgeon who admits a patient also bill for a discharge summary, and if so what code would apply?

A: There are separate discharge codes: 99238 if the process takes less than 30 minutes and 99239 if it takes more. Use 99234-99236 if discharge takes place on the same day as admission.
If the discharge is following surgery, then it is included in the global services for the surgical procedure and should not be reported separately. 

Take some time to read through the E&M section of your CPT coding book to see the full definition of the service and all the codes available. 


Q: Can you please send me 2005 coding information on Dermabond?

A: The introduction to the repair codes in the 2005 CPT-4 Manual states, "Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives [e.g., 2-cyanoacrylate (Dermabond), etc]." Medicare requires that HCPCS Level II code G0168 be reported when tissue adhesives alone are used.  


Q: The physician gave a diagnosis of "protuberant abdomen." Under review of system, she wrote, "Abdomen was abnormal on visual inspection." Can I code it as 759.9 -- Congenital anomaly unspecified? I can't find it under "protuberant," and under "abnormal" the book tells me to look under "anomaly."

A: The most appropriate code for this diagnosis can probably be found in the 780-796 section of ICD-9. This section deals with symptoms, signs, and ill-defined conditions. This is most likely not a congenital anomaly and there is no ICD code for protuberant abdomen. In addition, if the only place in the record this is discussed is in the review of systems you might want to check with the physician to determine if this really needs to be reported on the claim form.


Q: During a difficult resection of endometriosis and uterine fibroids, I performed a bilateral ureterolysis (50715) extensive excision of retroperitoneal tumors (49201), TAHBSO (58150), and excision of a separate vaginal fibroid. What combination of codes/modifiers can be used to maximize reimbursement for this 4.5-hour procedure for a difficult but benign disease?

A: While CPT 50715, ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis, has the highest Relative Value Units, it should not be reported if the procedure was done for any other diagnosis than retroperitoneal fibrosis. Based on your scenario, it appears that the best coding selection would be 49201-22 and 58150.

This is a provisional suggestion since I do not have access to the operative report. Your documentation will have to be very detailed, outlining each procedure, the difficulty involved in completing the procedures as well as the increased amount of time required to perform the surgeries. You might also need to include a cover letter/special report providing the reasoning for adding modifier -22 and what extra percentage you are requesting for the extra work.


Q: Please explain when it is appropriate to charge for supplies and wound dressing changes. Is this charge in addition to the E&M? Is it also chargeable when the nurse performs the dressing change alone? 

A: Typically, dressing changes are considered part of the E&M service, and the supplies are considered part of practice expense. If the nurse performs the activity alone, use E&M code 99211. Remember, you must meet the incident-to requirements.

There are two exceptions to this general rule. There are codes for application and dressing changes for local burns (16000-16036). There is also a code (15852) for "other" dressing changes when performed under anesthesia.


Q: Can you please clarify when the professional codes for chemotherapy administration (96410 and 96412) are appropriate?

A: Physicians can report the codes if the chemo is provided in a physician office setting as opposed to an outpatient hospital setting. In the physician office, the services are generally provided by nurses employed by the practice and provided under the "incident to" concept and requirements. Medicare has new G codes for 2005 when reporting injections and infusions, including chemotherapy administration. Codes G0359 and G0360 cross-reference to CPT codes 96410 and 96412. You should check your Medicare carrier bulletins or refer to the November 15, 2004 

 for guidance on the use of these new codes.

Q: What is the minimum number of antepartum visits required to bill a global delivery service such as 59400?

A: Neither CPT nor the American College of Obstetricians and Gynecologists defines the minimum number of required antepartum visits. Some payers, including some state Medicaid programs, require at least seven antepartum visits before the global code can be reported. Medicare's teaching physician guidelines refer to the concept of a minimum required number of visits but do not specifically set the number. You'll need to check with your local carriers.


Q: During a post-op for surgery, the physician decided to do an I&D. Can I bill separately for this procedure or is it considered part of the global package? 

A: The answer depends on the payer and the reason for the I&D. If the reason for the I&D is related to the surgery -- such as a complication --  then billing depends on the payer. Medicare does not pay separately for the treatment of a complication during the global period unless a return trip to the operating room is required. 

Other payers may pay separately for this but that is dependent on the payer's policies. There is no modifier required. You should select a diagnosis specific to the reason for the I&D.  


If the I&D was unrelated --  for example, if it was on another body site --  it can be reported to Medicare and other payers. Append the -79 modifier (unrelated procedure during global).


Q: If a physician removes a skin lesion, should the billing be held until the pathology report comes back, and we know if the lesion was benign or malignant? 

A: The proper CPT code for the removal of a lesion depends on whether it is malignant or benign. In addition, reimbursement is greater for the removal of a malignant lesion than it is for an equivalent-size benign lesion. Therefore, to assure proper coding and reimbursement, you should wait for the pathologist's report before billing. Make sure you have a system in place to ensure that "held" charges are not lost.

Q: We are doing a simple mastectomy on a patient who has Medicare. She is diagnosed with breast cancer. However, we also are removing the other breast prophylactically because of her fears. How should I code?

A: Generally, bilateral procedures are reported as 19180-50. Medicare likes to see the code reported once as a single line-item entry. In this instance, you need to include the ICD-9 code for the prophylactic removal which is V50.41 (prophylactic organ removal of breast). You should also check with your local Medicare carrier regarding coverage issues and reporting requirements. If there are other "medical" reasons for the second mastectomy, these should be communicated to the carrier and included on the claim.


Q: When billing for skin excisions and closure, how do you determine which is the primary code, and which to modify? Many times the closure costs more than the excision. Would this make it the primary code? When billing for both, is a modifier -59 appropriate?

A: First, keep in mind that simple closures (one-layer closures) are included in the excision code. You can code separately for repair by intermediate or complex closures using the -51 modifier. The -59 would only apply if the closure, somehow, was at a different site and part of a totally separate incision. List the higher value procedure first and modify the procedure of lesser value. 
The modified procedure gets reduced reimbursement, and it's better to get a percentage cut off a small fee rather than a big one. 

If you do multiple closures -- some to one site, some to another -- you can modify those with -59. When choosing between -51 and -59, it helps to think -51: same site, same incision; -59: different site, different incision.


Q: When billing for global fracture treatment, code 27788, can we charge the global fee plus supplies? Please clarify if "supplies" means a short leg cast, code 29405, or does it simply mean charging for two fiberglass cast rolls? Presently, we only charge for the initial treatment 27788 and nothing else. We then charge a cast application charge if the cast needs to be changed during the global period. 

A: Code 27788, like others in the musculoskeletal system section, include the application and removal of the first cast or traction device only, so you do not charge for it. Re-casting or replacing the initial cast can be billed, even during the global period, using the appropriate code from the 29000-29590 series.

Please note that the claim may get denied since the payer may mistake it for a resubmission of the original cast application. Include medical documentation to support the re-casting when you submit the claim.

You can also bill for supplies using the correct HCPCS code. The CPT codes describe only the services rendered.


Q: Our patient has Unicare as primary and Medicaid as secondary coverage. We as an OB/GYN file the global OB care and delivery 59400 to Unicare; then when we go to file Medicaid, is it illegal to change the CPT code? Medicaid does not pay for the 59400. They want 59410 (delivery only). 

A: It is appropriate to change the code when it is a requirement by the payer, such as the situation with Medicaid. I would make certain, however, that you have the instructions in writing.  

Emily Hill, PA-C, president of Hill & Associates Inc., has 14 years of experience as a healthcare consultant. She has worked with numerous academic and private practices on coding, reimbursement, compliance, and practice management issues. She currently serves as a representative on the American Medical Association's Correct Coding Policy Committee, the Health Care Professionals Advisory Committee Review Board for the Relative Value Update Committee (RUC), and the National Uniform Claim Committee.

This article originally appeared in the April 2005 issue of 

Q: If a medical provider and a psychologist see a patient on the same day will Medicaid pay for both visits?

A: You are more likely to get reimbursement for both providers if the patient is being seen for a nonpsychiatric medical condition by the medical provider and a mental health issue by the psychologist. If both encounters are related to the mental health diagnosis, it may be more difficult to get reimbursed for both providers. You need to check with your state Medicaid program since policies vary by state.

Q: How can we get reimbursement for random drug testing? What are the codes for patients on controlled substances or with history of substance abuse? Do Medicare and Medicaid pay for this? What is the rate for in-office testing?

A: CPT codes 80100-80101 describe drug screens and code 80102 describes drug confirmation. Therapeutic drug assays are reported using code 80150-80299 and drug quantitation is reported using codes from the Chemistry section, 82000-84999. Medicare does not pay for random drug testing. You need to check with your Medicaid carrier to determine its specific policies.

Q: Is CPT code 44143 appropriate for an end colostomy with creation of a Hartmann pouch when only a short segment of colon is excised rather than a more formal colon resection? There is a code for skin level cecostomy or colostomy done as a separate procedure, which would be the only other choice. I have used that more for loop colostomies.

A: Based on the information you provided, it would seem that code 44143 is most appropriate since that code describes a "Hartmann type procedure."

There is no minimal amount of resection that must be done to report the partial colectomy codes. Code 44141 describes a partial colectomy with skin level cecostomy or colostomy. You should select the code that you feel more accurately describes the work you performed. 

Relative value units (RVUs) can sometimes be helpful in comparing the work between two CPT codes. Code 44143 has 36.20 RVUs and Code 44141 has 31.98 RVUs under the Medicare fee schedule, which is also used by many payers. Based on Medicare average allowables that translates into about a $160 difference in physician payment between the codes.

Q: I have recently discovered some OB/GYN practices are billing Q0091 (Pap collection code) to commercial carriers and getting paid for it, in many instances in addition to the charge for the annual exam. We use it for Medicare, but is it also a code that can legitimately be used for commercial payers?

A: Q0091 was created to describe a unique benefit covered by Medicare. The American College of Obstetricians and Gynecologists considers the collection of the Pap to be a component of the pelvic exam (E&M service) and does not support the separate reporting of Q0091 to payers other than Medicare.

There are some payers in the country that have determined they will pay separately for the collection of the Pap smear when performed at the time of a routine preventive exam. They have provided written instructions to bill the Q0091 as an additional code. If the payer has issued that instruction, I suggest you report the code. If not, I do recommend that the Q0091 be reported.

Q: How should the following surgery be coded: Debridement of partial tear, patella tendon and drilling inferior pole of patella and multiple longitudinal tenotomies?

A: It's difficult to code a case without seeing the actual operative report and understanding the exact anatomic areas involved, diagnoses, etc. CPT code 27307 describes a percutaneous tenotomy of multiple tendons (adductor or hamstring).

Debridement of an involved tendon is part of the procedure and should not be reported separately. The tenotomy itself is a component of a number of surgical procedures on the knee, therefore it is bundled into many of the surgery codes.

If there was no other surgery performed that day, code 27307 can be reported. If another procedure were done on the knee, you would need to make sure the tenotomy is not an inherent component before you reported the tenotomy separately. Medicare's Correct Coding Initiative (CCI) may be helpful in this regard.

Q: What are E codes and how does their usage/nonusage affect reimbursement? Are they just used for informational purposes by CMS [the Centers for Medicare and Medicaid Services]?

A: E codes are used to classify external causes of injuries, poisonings, and other adverse effects (e.g., collision with motor vehicle on public highway). The E codes are located in the last section of the ICD-9 coding book. They are, indeed, used by people at CMS or NIH to track injuries, etc., on the population.

They may be used by some third-party payers to help support the medical necessity for care, and so can improve payment.
According to ICD-9 guidelines, they should be attached to poisoning, burns, and other injury cases. To code ICD-9 for burns, for example, the first diagnosis code(s) should report the site and degree of burn, a second should describe the extent of the body surface burned (optional), and a third E code would show how and where the burn happened.

For example, if the patient had a deep third-degree burn of the abdomen and chest areas resulting from her clothes igniting after a gasoline spill, you'd code 942.49, 948.11, and E894. (Use the Rule of Nines to determine the percent of body burned.)

Similarly, for poisonings, code first the applicable poisoning code for the substance from the list of E codes, then code the condition caused by the poisoning, and third, use an E code to describe the cause of the poisoning (accident, suicide attempt, assault, undetermined).

Q: Please explain when it is appropriate to charge for supplies and wound dressing changes. Is this charge in addition to the E&M? Is it also chargeable when the nurse performs the dressing change alone?

There are two exceptions to this general rule. There are codes for application and dressing changes for burns. There is also a code (15852) for "other" dressing changes when performed under anesthesia.

Q: What is the correct code for Department of Transportation (DOT) physicals for truck drivers?

A: Codes 99455 or 99456, work-related or medical disability evaluation services, are usually appropriate for DOT physicals. However, check first with your state's DOT to see if they have other requirements.

Q: Is a doctor allowed to bill an E&M code with codes 98925-98929 for osteopathic manipulative treatment (OMT)?

A: You can report E&M services, using modifier -25, if the patient's condition requires a significant, separately identifiable E&M service, above and beyond the usual pre-service and post-service work associated with the procedure. Don't automatically or routinely report an E&M service; you need to meet the requirement above.

The E&M service may be caused or prompted by the same symptoms or condition for which the OMT service was provided; you don't need different diagnoses to report the OMT and E&M service on the same date.

Generally, the doctor of osteopathy will have evaluated a complaint and then made the determination to perform a manipulation or the patient is being treated for other conditions at the same visit. The documentation should support the fact that both services have been provided.

Q: Part of determining the level of medical decisionmaking involved in an E&M visit is whether the presenting problem is a new one. Does that mean new to the patient or new to this physician?

A: A new problem is a problem new to the physician. It is the physician's work effort that is relevant for the level of coding.

Q: When coding for colonoscopy with multiple polyp removal using both snare and hot biopsy would you use both codes?

A: According to CPT rules, both codes can be reported since the lesions were removed by different techniques. The secondary procedure should be reported with a -59 modifier. Medicare guidelines also allow both procedures to be reported. Other payers may have their own payment rules and bundle these codes together.


Q: If a physician assistant and physician both see a new patient, can the service be billed under the physician's name? 

A: Yes, if the physician sees the patient and documents his participation in the care of the patient, then the physician can bill for the encounter. Under Medicare's incident-to rules, however, the physician assistant is not allowed to see a new patient by herself and bill the service incident-to under the physician's name. The PA can see a new patient without the physician present if the service is reported using the PA's name and Medicare provider number. Specific state supervision rules must be followed.

Q: One of our doctors saw a patient at an outpatient clinic, evaluated him, and then decided the patient needed to be admitted to the hospital. Another of our doctors admitted and followed the patient in the hospital. This is the same group practice and same tax ID number. Physicians are in the same specialty. Can both services be billed? 

A: No, the inpatient care codes include all E&M services provided in conjunction with the admission. Thus, the office visit is included in the admission to the hospital. Also, payers generally treat all physicians of the same specialty in the same group practice (tax ID) as if they are a single physician. This means that services included in the payment to one physician will not also be paid to another.

Q: How do I code for ileoscopy with biopsy of terminal ileum at the time of colonoscopy?

A: According to the CPT Assistant, a colonoscopy is "the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum." Therefore, the appropriate code is 45380 (colonoscopy with biopsy, single or multiple). There is a distinct CPT code for ileoscopy with biopsy when performed through a stoma (44382).

Q: How do you know when to bill 99070 and when to bill with a more specific code?

A: There are specific HCPCS codes to describe supplies, materials, and drugs. When a specific HCPCS code is available, it should be reported. CPT code 99070 is very general and may not be recognized by many payers.

Medicare will not pay for supplies in addition to a visit or procedure since the supplies are included in the practice expense component of the relative value units assigned to the codes. Other payers may follow the same guidelines. Injectable drugs are paid separately depending on specific coverage criteria.

Q: How should we bill Medicare for an office visit and a B12 injection?

A: Beginning in January 2005, Medicare reimburses for therapeutic/diagnostic injections (HCPCS codes G0351, G0353, and G0354) provided at the same time as an E&M service.


Medicare will continue to reimburse separately for the drug itself using the appropriate HCPCS J code. Therefore you report the E&M code, G0351 (IM injection) and J3420, the HCPCS code for B12. Be aware there are coverage restrictions on B12 injections. Make sure that your patient has one of the conditions that is covered by Medicare. If not, or if you are uncertain, have the patient sign an Advanced Beneficiary Notice.

Q: When, if ever, can we bill both for collecting a specimen (CPT code 36415) and for conveying a specimen (CPT code 99000)? What if a patient comes into the office for lab work that is performed in the office? What if a patient brings in a sample or we go to their home and collect a sample but send it to a laboratory?

A: CPT 99000, handling and/or conveyance of specimen for transfer from the physician's office to a laboratory does not apply when you are collecting and handling the specimen in the physician's office. The specimen isn't really conveyed anywhere. You may only bill 36415, the venous puncture to collect the specimen.

If a patient brings the specimen to the office but you send it out you could probably bill 99000, assuming that you actually do the conveyance rather than having the lab come to your office to pick it up. However, you can't bill the 36415 since you didn't collect the specimen; the patient did. 

The only scenario that works? If someone from the office goes to a home, collects a specimen, and then takes it to the lab.

Q: A patient comes in with superficial injuries and contusions to the elbow and the knee. Would you code both the superficial injury and the contusion or one or the other?

A: Code for the more extensive injuries - in this case, the contusion of the elbow, 923.11 and the contusion of the knee, 924.11. These codes cover the superficial scrapes and abrasions in the same areas.

Q: Gastroenterologists sometimes refer patients to our ophthalmology practice because ulcerative colitis may cause eye problems in children. What ICD-9 code should I report if, upon examination, there is no eye problem?

A: Use either V80.2 (special screening for eye condition) or V71.89 (observation for other suspected condition not found) and then the appropriate ICD-9 code for the ulcerative colitis (556.0-556.9). This should support the medical necessity for providing the exam. If necessary, you can appeal the claim with documentation. Make sure you clearly document that it is not a routine eye examination. 

Q: There is a specific billing code for an electrical cardioversion. Is there a corresponding code for a chemical cardioversion for therapeutic or diagnostic purposes?

A: Physicians can't bill for the infusion therapy itself. Since pharmacologic or chemical cardioversion is a procedure that generally takes place in the acute care setting, rather than the office, it is considered a facility charge, not a physician charge. The physician charge is included in the E&M service provided, such as: 99354-99357, prolonged physician service; 99291-99292, critical care; 99221-99223, initial hospital care; 99231-99233, subsequent hospital care; 99261-99263, follow-up inpatient.


However, if the chemical conversion did take place in the physician's office, you can bill CPT code 90780, which indicates the first hour of an IV infusion for therapy/diagnosis that is administered by a physician or under the direct supervision of a physician. In addition to the infusion code, you need to report the name and dosage of the drug using the appropriate HCPCS level II code. Also, based on the physician's documentation, you would bill the appropriate E&M level of service.

Q: How would you code an allogenic bone marrow donor? Do you bill the donor's insurance or the insurance of the recipient?

A: CPT 38240 describes bone marrow or blood-derived peripheral stem cell transplantation. In order to determine whether you bill the donor's insurance or the patient's you will have to speak with the carriers involved to see what their coverage policies are regarding this procedure. The coverage may vary based on the type of policy the donor and recipient each have in place at the time of the procedure.

Q: What codes should be used when the hospital requires us to do an H&P before outpatient cardiac cath and EP studies?

A: The H&P required by the hospital is not separately billable. Medicare considers this included in the payment for the cath and EP studies. 

Q: Is the past, family, and/or social history part of an E&M exam required documentation for an interval history?

A: The interval history is associated with follow-up inpatient services. It means the events from the previous inpatient encounter (day prior for example) to the current day. A past, family, and/or social history is not required for an interval history since these issues don't change on a daily basis.

Q: Our nurse does many insulin pump initiations. She spends a minimum of two hours teaching the patient how to use the pumps. We are not billing for her time because we are unable to find the appropriate codes. Any recommendations?

A: There are no specific codes to describe insulin pump training. The only available CPT code is 99211. I recognize that it does not adequately reimburse for the service, but it is the only valid option at this time. In some instances, you may be able to negotiate with the payer to get coverage for this training. However, the manufacturers often include training as part of the device cost, so it can be difficult to obtain additional reimbursement for teaching.

Q: Can you bill CPR or ECGs separately from adult critical care codes?


A: Neither CPT nor Medicare prohibits billing for both CPR and critical care assuming they are distinct services and both are clearly documented. ECGs are separately billable.

Q: When is it appropriate to use CPT code 99435?

A: Code 99435 is used when newborns are assessed and discharged from the hospital on the same date. If the physician sees the patient on one day and discharges the infant on another day, then 99431 (history and examination) is reported for the first day and 99433 (subsequent hospital care) is reported for the next day. The date the service was provided determines the appropriate code selection.

Q: What can you tell me about the new code for assisted living facilities? Can I use home service codes if seeing patients in assisted living apartments or condos?

A: Medicare has recently added a place of service code, 13, for assisted living facilities. They define an assisted living facility as a "congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some healthcare and other services."

If you are delivering care to a patient in such a setting, you should not use CPT codes 99341 through 99350, the Home Services Codes. Those are for services rendered in an individual's private residence. The appropriate category of code is "Domiciliary, Rest Home, or Custodial Care" (99321-99333).

Here is medical coding guidance on mental health conditions; random drug testing; tenotomy; using E codes; and much more.