Coding questions on Medicare denials, TCM billing

October 12, 2018
Bill Dacey, MBA, MHA, CPC, CPC-I

Coding expert Bill Dacey answers your latest coding questions, including an inquiry on why Medicare denied an initial visit claim.

Q: Medicare is denying initial visits when advanced registered nurse practitioners (ARNPs) bill for an initial visit and another ARNP or physician from a different specialty also bills an initial visit within three years. Is there a reason why they cannot bill for an initial/new patient visit? Is there specific coding we need to use in this situation?

A: I first said the issue is probably that nurse practitioners (NPs) don’t have specialty assignments, so I asked exactly what the denial said. And you gave me Medicare’s response: “Medicare will not allow more than one new visit during a three-year time frame by the same provider National Provider Index (NPI) or providers in the same specialty within the same group.”

You have assigned Taxonomy Code 50 to your NP, the correct taxonomy code. But as explained above, these don’t have specialties assigned to them. Compare the 50 Taxonomy code to the 89 Taxonomy code for clinical nurse specialists, where they do give them different specialties. Although you have a different taxonomy code, it isn't exactly identified as a different specialty. I know this is a technicality-but it seems to be where they have you.

Try asking Medicare the broader question as to whether or not these separate services, in separate specialty practices, are somehow "homogenized" because an NP provides the services instead of a physician. Ask them why they don't distinguish between practices for NPs as they do for clinical nurse specialists. 

I'm not sure if you can prevail here. You have the spirit of the law on your side; they have the letter of the law on their side.

 

Q: A transitional care management (TCM) code 99496 was billed for a visit, but the patient was in a hospital in Florence, Italy. Per the CPT guidelines, can we bill a TCM if this was in a different country?

A: There is no reason you can't bill this 99496. The only required element beyond the time frames and the moderate or high medical decision-making is that medication reconciliation be performed at this visit. Medicare is interested that the patient not be rehospitalized back in the United States!

 

Q: My practice has been told the review of system (ROS) needs to cross-reference the past medical history. For example, if a patient has a history of coronary artery disease and had a stent placed, the cardiovascular section of the ROS would need to reference that. This seems excessive. Is it required?

A: It is always possible that a given payer could have specific documentation requirements, but when it comes to E/M visits, the federal documentation guidelines have these pretty well covered, and they have been for years.

The ROS is principally a diagnostic tool. Providers are looking for signs and symptoms that may contribute to their differential diagnosis when assessing a problem. That is why the federal guidelines describe ROS as "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced."

The next area is, of course, the past, family, and social history. So no, the federal guidelines do not suggest or in any way actually link these two components of the chart. There may sometimes be a reason to mention a particular history element as it becomes relevant in the present, but there is no requirement that you do so. 

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Email him your questions at billdacey@msn.com.