Coding: Billing for locum tenens; ICD-10; CMS guidelines

October 19, 2010

In this issue, a question that asks how many new codes are in the ICD-10 code set.

To code or not to code?

Q: Are you aware of any studies that show that physicians selecting their own E&M, CPT, and ICD-9 codes for inpatient services are faster and as accurate as having those codes abstracted by a certified coder?

A: I know of no such studies. But there are several things to consider here. The provider of the service is the only one that really knows what was really involved in providing the service. If the documentation of the event is complete in every way, the abstracted information can then match the provider’s own knowledge. But we all know that that is seldom the case the documentation is usually somewhat less than the event.

If your goal is 100 percent compliance, then a coder abstracting from the documentation assures that your code will not exceed supporting documentation, but at what cost?

It is expensive to have coders abstract everything, and assuredly takes somewhat longer, and the total cost is the coder cost plus the loss of coding revenue due to any downcoding. Compare this to the potential liability of under-documentation and any over- or under-coding.

Your best bet is to give the providers the tools to code their own work. EHRs, Web-based nets, handhelds, and ICD-10 oriented systems are making this easier and faster. Providers are the source of the information and should be accountable for the codes.

Outpatient inquiry

Q: We have a physician who is currently billing for infusion services in a hospital outpatient department. The department is asking for clarification as to whether or not this is appropriate. The services are: 96365-IV Infusion and 99195-Phlebotomy therapeutic.

A: According to CPT the 96365 code was not intended for use in the clinic or in the hospital but rather in a free-standing outpatient office. The provider is allowed to bill the 99195 in this setting - but it has no physician work RVU. Is the physician actually drawing the blood? Normally physicians don’t do that themselves. If they do, they should charge for it.

Guideline updates

Q: We recently had a compliance administrator question why we were using "old data" to audit physician charts. She was referring to the 1995 and 1997 federal guidelines. Are there newer rules we should use?

A: Not from CMS itself. The Evaluation and Management Service Guide online directly references the 1995 and 1997 guidelines, although it does include some later, slightly more definitive information.

A better question is whether or not they are the best source or tool to evaluate your providers. For Medicare each carrier or MAC is allowed to interpret these rules their own way, and many have their own E&M evaluation tool. Some are on their Web sites, some not. Look at your carrier’s Web site to see if they have a specific tool for your state or region, or call them and ask. But if they don’t - we all default to the 1995 and 1997 guidelines. Old isn’t necessarily bad.

Locum tenens in, provider out

Q: Some providers are permanently leaving our practice and we are exploring opportunities of employing locum tenens providers. If I understand correctly:

• The substituting physician should bill under the departing physician's NPI, with the substitute's NPI on file;

• If the substitute is a "hired gun," claims should have modifier Q6 appended;

•If the substitute has another practice (solo/group) - claims should include modifier Q5; and

•Billing could continue for 60 calendar days, but after that the remaining physicians should share the workload.

A: You essentially have it right except for maybe a couple of things.

I don't think you would ever use Q5. When they talk about reciprocal billing they mean that physician A covers physician B on weekends and the like and they basically cover one another's patients and bill in one another's name.

That's not what's happening here. One of your providers is gone. There can be no reciprocity in your current situation.

Use the Q6 when you hire someone from the outside - it has a shelf-life of 60 days.

After that, don't start swapping numbers around. A lot of people get way too creative after 60 days. Look at the Medicare guidance online for details on this.

ICD-10 411

Q: I’m pretty confused about ICD-10. I hear conflicting things about how many codes there will be. I’ve heard that there are 60,000 plus diagnosis codes, then I hear numbers that are more than double that. Do they really know?

A: Yes, the ICD-10 codes sets are pretty well defined, but it is understandable that you could be confused. The ICD-10 CM - the diagnosis codes - has 69,101 codes with more to come in 2011. These include your signs and symptoms as well as E-codes and V-codes. This compares to 14,000 plus codes in the current ICD-9. These are the codes that physicians use on CMS-1500 forms to communicate why health services were provided.

But on the other end of the spectrum is what is called ICD-10 PCS. This is the newer version of the old ICD-9 Volume 3, the procedure codes traditionally used by hospitals to report procedures. ICD-10 PCS will contain close to 87,000 procedure codes compared to the current 4,000 or so ICD-9 CM procedure codes.

When you add together ICD-10 CM and ICD-10 PCS you have more than 150,000 codes.

Complaint complexity

Q: I know that every visit needs to have a chief complaint, but I was recently told that information in the chief complaint can’t be used in the HPI. Is this true?

A: It is the very rare regulator or reviewer that would take that approach. The rule is that there needs to be a chief complaint, and one CMS definition is: the “CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words.”

The HPI on the other hand is “a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.”

If your chief complaint were knee pain, it is certainly permissible to describe the duration, severity, etc., and the knee itself qualifies as the location of the problem.

Talk of "double dipping" is usually about information shared between the HPI and the ROS, not the HPI and the CC.

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 or

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