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Coding Questions: Resident Billing Without a Teaching Physician


Is there any "primary-care setting" where a resident may bill the office visit without a teaching physician, other than in the primary-care exception?

E&M in Addition to Preventive Service

Q: I recently read that the assessment of a patient's chronic problems is part of the annual exam and shouldn't be billed separately. The author went so far as to say that it is dangerous and ill-advised to bill a preventive service and problem visit in these circumstances? Is this correct?

A: There are many opinions about various aspects of coding, and I have also seen guidance that is similar to that which you reference above. But both Medicare and the AMA, which owns the CPT codes and descriptions, see this issue the same way (and in a way that contradicts what the author you reference recommended).

Here is some guidance on how to properly bill in this situation:

When performing a medically necessary E&M service at the same time as a preventive service, add a -25 modifier to the office visit code (usually the 99213 or 99214 that you bill in addition to the preventive service).

Determine the level of the additional E&M the same way you would a standalone problem visit. When you are dealing with one to two stable chronic problems (often treated prescriptively), or an acute uncomplicated problem (also usually treated prescriptively), use 99213. When dealing with three stable chronic problems, one stable chronic problem and one worsening, or really any combination of three problems (acute and chronic), use a 99214 in addition to the preventive service.

This guidance of course, assumes that you are actually managing these problems. A list of chronic problems in the HPI and/or the A/P does not necessarily indicate that you managed those problems that day. That's why it's even more important in the age of EHRs to give some relevant detail in the HPI as to the status of those problems, and likewise in the A/P, to make it clear that the problems are stable, worsening, etc., and what the specific treatment plan is.

So, if a patient presents for one of his four problem-oriented visits dedicated to following his hypertension and hyperlipidemia, and at the time of that visit it is also time for the patient's annual preventive exam, you can code both the problem management code and the preventive code, as long as both services are clearly documented.

Subcontracting With Independent Laboratories

Q: I am a family physician and I perform lab draws for my Medicare, Blue Cross Blue Shield, and UnitedHealthcare patients. I send these labs to LabCorp to perform the labs, which we then bill. Medicare is refusing to pay for these labs. First, it stated we had a problem with our CLIA certification. When we sent it in, Medicare turned around and stated that we needed to append a modifier to these labs. Do you know of this modifier? Will Medicare pay us for subcontracting from LabCorp?

A: This is actually pretty straightforward. You want modifier -90. See the Medicare definition below:

"Medicare Part B modifiers – 90

Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number. For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis."

Resident Billing Without a Teaching Physician

Q: Can you tell me if there is any "primary-care setting" where a resident may bill the office visit without a teaching physician, other than in the primary-care exception?

A: It sounds like you are asking this in relation to a setting within the context of teaching. In order to qualify for payment under the Medicare program, the setting needs to be part of "an approved residency program." Certain primary-care offices outside of the facility can be considered part of the program.

If you are asking whether a resident's work that is wholly outside the scope of the program can be billed without a teaching physician, the answer is that since the resident is a licensed medical professional, he can moonlight.

I would suggest that you check with your state insurance board and regulatory entities to determine any specific requirements.

Missing HPI/Chief Complaint

Q: If a visit note is missing the HPI/chief complaint, can we still code it based on exam and medical decision making? I am under the impression that the chief complaint must be documented to assign a level of service to the visit. 

A: The 1997 Documentation Guidelines for Evaluation and Management don't say that a note "must" have these components. For the chief complaint, the documentation guidelines say that, "The medical record should clearly reflect the chief complaint."

The guidelines also say that the chief complaint can be part of the HPI. The guidelines don't address whether these elements need to be present if you are basing your code on other note components. In other words, if you have a solid exam and assessment and plan area (A/P) on an established patient, then per the CPT manual you don't really need a history section at all.

However, I think most folks would agree that all stories benefit from an introduction. Starting in the middle with no content at all is a bit odd. A note would seem incomplete without some semblance of a chief complaint and/or HPI, although we sure do see some skinny notes sometimes.

For an established patient, I'd be comfortable rating the occasional note without the HPI or chief complaint, though it is not the best practice.

Do be aware that one Medicare carrier took the position a couple of years ago that even though CPT has a "two of three" (history, exam, decision-making) mechanism for choosing certain codes, its interpretation was that one of the three did not did need to meet the level of the other two, not that the third component did not need to be included. In other words, the carrier said that all three components always need to be there - it's just that one is allowed to lag significantly behind the other two. This was the most stringent interpretation of these guidelines that the coding community had ever heard of, and the position was roundly criticized. Although there may be a payer out there that would take this position, it is not main stream. That said, get your docs to put a "front-end" on the notes. That should make it easier for everyone.

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.

This article originally appeared in the July/August 2014 issue of Physicians Practice.

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