Problem visits with counseling; coding for suture removal; mixing exam types?
Problem visits with counseling
Q I know that I’m allowed to bill for annual health maintenance visits as well as problem-oriented services on the same day. The thing that has come up is that sometimes the problem portion of the visit is counseling, and my office manager says I can’t bill for both services when the problem part involves counseling. Is this true?
A Great question. The factual answer is that it is not true - you can bill for both when you perform both services. But what I suspect your office manager is alluding to is a potential documentation problem - and perhaps even a reimbursement problem with this scenario.
Normally when you bill the preventive code for the annual and an office visit code to cover the problems handled, the problem-oriented code is supported by the HPI and assessment and plan portions of the chart. Often the HPI takes the form of the status of various chronic ailments, but it can be the more acute descriptors normally associated with the HPI.
In your situation above - whatever the problems are that require counseling could easily meet these parameters, and as long as there is an HPI, maybe a small subjective ROS, and the requisite assessment and plan - you likely have documented the problem visit above and beyond the health maintenance one.
The potential problem arises if you try to bill the problem code based on time spent counseling. Often, when counseling is the predominant character of the visit - you can code for it by time - and the supporting documentation takes the form of “spent more than half of an X-minute visit counseling on Y.” And this is sufficient.
But realize that the times associated with the problem codes are total encounter time. The fact that you spent more than half of that time counseling simply qualifies you to use time to code. And therein is the potential problem at the heart of your question. The “total” encounter time in this case would appear to include the preventive service. To bill the problem portion based on time spent counseling, as opposed to the actual management reflected in the HPI/decision-making portions of the chart, you’d need to segregate the problem visit from the preventive visit in terms of time.
If this is the route you choose, you might try something like this: “Following the preventive portion of today’s visit, 30 minutes was devoted to addressing problem X. Of this 30 minutes, more than half the time was spent counseling the patient on Y.”
This should have the effect of separating the two different aspects of the encounter, and allow for a fairly concise description of the problem-oriented portion and its required supporting documentation.
Code for suture removal?
Q A patient came in the other day for her routine exam, including her Pap and pelvic, and a complaint of some sporadic vaginal bleeding. During the exam I found a couple of retained sutures in the front part of the superior vaginal vault. These had formed an inflammatory granuloma causing some bleeding. The patient had a hysterectomy four years ago.
I spent at least 25 minutes trying to remove these difficult-to-get-to sutures without causing anymore problems. They were successfully removed. I’m now being told that there is no code for this procedure. Surely there is way to get something for my time and skill?
A There is no code for suture removal, and the only code for vaginal foreign body removal (57415 - removal impacted vaginal foreign body) requires anesthesia. It sounds like you just got the sutures out, likely taking care not to excise any tissue. It also does not sound like it was encysted, so that eliminates 57135.
There is a note under 57415 in the CPT manual that states “for removal without anesthesia of an impacted vaginal foreign body, use the appropriate E&M code.”
This presents a difficulty given that you already had an E&M going, either preventive, problem-oriented, or both. The additional exam involved is not likely to get you much in terms of moving the code to a different level, assuming there is a problem-oriented code. Likewise, the history isn’t going to change much on terms of code levels. If you had a 99213 going previously, this could move it towards a 99214.
I would suggest using the add-on code 99354 for prolonged services, but that requires a minimum of 30 minutes and this took only 25 minutes - or was that a guestimate? Maybe you would want to revisit the “at least” part of your question. Do remember this qualifier if something like this arises again and takes that amount of time.
What this seems to leave us with is not much. There does not appear to be a CPT for unlisted procedure in the vagina. You could try 57200-52, the code for placing sutures to repair an injury of the vagina, with the 52 modifier to indicate that this procedure is a lesser version of that one - in fact, the reverse. Some might consider this a stretch, but at least it opens the dialog with the payer. Let us know how it turns out!
Mixing exam types?
Q Can I mix and match bullet points from the general multisystem and single organ system examinations in the 1997 Documentation Guidelines for Evaluation and Management Services?
A This would depend on the carrier. To be on the conservative side I would say no. Although the 1997 guidelines themselves only call for a certain number of points or elements to qualify for a certain level, the general theory is that you are using one of the exam formats.
The specialty exams were set up to accommodate concentration or interest in specific organs systems and related systems. The general multisystem exam was just that - general. If that doesn’t get you what you need, you likely need a specialty one.
Or, can you use the 1995 guidelines? Sometimes people lock themselves into the 1997 set of rules because they think they are newer, or a higher standard. They are newer, but they simply allow for specificity - they are no more valid than the 1995 guidelines. The 1995 set actually allow less specificity. Maybe you don’t need to cross between exam types.
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 email@example.com or firstname.lastname@example.org.
This article originally appeared in the April 2010 issue of Physicians Practice.