Coding Questions? We’ve Got the Answers

June 1, 2010

Billing for hospitalists; smoking cessation documentation; patients’ paperwork; group visit codes.

Billing for hospitalists
Q
We are trying to put together a hospitalist program with a local community hospital, utilizing local practicing physicians. My question is, when the hospital bills on behalf of the hospitalists for their services rendered at the hospital, will third-party payers have difficulty with generating payments to the same physicians who also have their tax IDs for their separate private practices?

A You really need to get the help of the hospital legal staff or a healthcare attorney to be certain you get this right. However, if the hospital and your colleagues are forming a group that will be a billing entity in its own right, then you will have a separate tax ID number.

The individual NPI numbers can be associated with more than one tax ID, as an individual provider can work in a variety of settings and for more than one entity. A given payer’s claims processing software should be able to sort out which tax ID and which providers within that are being paid. The tax ID controls the place the payment is sent in most cases.

Smoking cessation documentation
Q
How do I code for smoking cessation work, and what do I need to document?

A The CPT manual has a section called Behavior Change Interventions, Individual. In it are two codes that cover smoking cessation and two codes that cover alcohol and other substance abuse structured screening services. They are all based on time and content.

Code 99406 describes a smoking and tobacco use cessation counseling visit between three and 10 minutes long. The note should state the context and the duration of time spent. A brief description of the counseling content and treatment options provided is desirable. Some Medicare carriers have indicated that some treatment, often of the prescriptive variety, needs to be given in order for the claim to be paid.

Code 99407 describes the same service where the duration of the counseling exceeds 10 minutes. Some carriers will pay for this code on the same day as another E&M service.

Medicare will cover two quit attempts per year. Each quit attempt may include a maximum of four intermediate or intensive counseling sessions, with the total annual benefit covering up to eight sessions in a 12-month period. The healthcare provider and patient have the flexibility to choose between intermediate and intensive counseling.

To be eligible to receive this benefit, a beneficiary must have a condition that is adversely affected by smoking or tobacco use, or that the metabolism or dosing of a medication that is being used to treat a beneficiary’s condition is being adversely affected by his or her smoking or tobacco use.

Patients’ paperwork
Q
Can I bill for doing paperwork for patients?

A Yes, there is a code that would generally cover that. CPT code 99080 covers “special reports such as insurance forms, more than the information conveyed in the usual medical communications, or standard reporting form.”

So, you can bill for it, but the better question is whether it’s covered. Because many insurers do not pay for this code, you may have to go outside coverage to get paid for it.

Many providers simply post a notice in the office indicating that forms will be completed for a flat dollar amount, perhaps contingent on time or complexity of the forms. You may simply wish to inform patients that there is a cash fee for filling out forms since this is usually a noncovered service.

Group visit codes

Q I run a lipid clinic and believe I have found a way to treat patients with the same illness efficiently and effectively. I have about 20 patients come to our clinic conference center in the early evening. My nurse checks vitals on them all, we have all 20 charts available, and she goes over their recent labs with them. I lecture them on diet, health maintenance, and medication.

I make a note in each chart that supports a 99213 based on history and exam. One consultant told me this may not be proper. Is there a problem with this approach?

A Yes, there is a problem here. It is certainly efficient and likely a good use of your time to deal with patients collectively in this fashion. However, billing 99213 individually to patients for services that are provided to a group would be considered fraud. I personally checked with one of the largest Medicare carriers in the country, and they were not pleased with the prospect you outline. When I indicated that by looking at your individual note, they (Medicare) would likely not be able to tell that the services were provided in a group setting, the Medicare representative was more than unhappy.

There are codes for services in a group setting, codes 99411 and 99412, and they pay significantly less than a 99213 - but they are the correct code. The codes represent 30 minutes and 60 minutes of education, respectively.

If you take an unadjusted fee schedule amount of roughly $40 payment for a 99213 - multiplied by your twenty patients - that’s $800 for the hour or two worth of work - not exactly the going Medicare rate for noncritical E&M. This would not be OK with them.

The work RVU for 99213 in 2010 is .97. The work RVU for 99411 is .15 and for 99412 is .25. Even the one hour code is only a fourth of the 99213 rate. As you can see, these are different enough to raise concern.


I have heard of groups billing similar events with a 99211. It sometimes takes the form of a group prenatal session, a blood pressure clinic, etc. But they aren’t individual visits.

When you read the description for a 99213 in the CPT Manual, it refers to “a visit for the evaluation and management of an established patient.” It doesn’t say “individual,” but it doesn’t say “patient(s)” either. The 99213 is for an individual visit - don’t test that one.

Coding for suture removal
Q
I was just reading the Physicians Practice April 2010 Coding Questions. I really like this article each month, I always learn something.

I don’t totally agree with your answer to the question in regards to a code for suture removal. Your first sentence, “There is no code for suture removal,” is incorrect.

There is a HCPCS code for this: We use it whenever a patient presents with sutures put in by another provider, ER or Urgent Care, or a surgery. It is S0630 Removal of sutures by a physician other than the physician who originally closed the wound (not valid for Medicare). We have no problem getting our managed care payers to pay this code. If there is also an E&M billed, I would put a modifier 25 on the E&M and modifier 59 I on the S0630.

-Cynthia Szuch, practice manage
Carrboro, N.C.
A Excellent! I never saw that code before - has it been around awhile? I'll look through some of my past HCPCS books. I’ve been talking to folks about this issue for years and this is the first time that this code has come to my attention - great find. I wonder how long I’ve had this wrong! Also, great feedback on getting commercial payers to pay using the code.

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 billdacey@msn.com or physicianspractice@cmpmedica.com.
The following coding questions were answered by Pamela L. Moore, CPC.
Admit and ICU
Q
When a patient is admitted to the hospital and goes directly to the ICU, can you bill for both the admission and critical care?

A It depends on whether the services provided for the admission meet the definition of a full admission. In other words, how “immediate” was the ICU transfer? You should be able to use the code for initial hospital admission, 99223, and then code the critical services with 99291 (critical care, E&M of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (each additional 30 minutes) if the encounters meet the criteria for those codes. Append modifier –25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to the critical care code (99291), and provide documentation supporting your use of two E&M codes on the same day.

The situation you describe is covered in the Medicare Carriers Manual. It says, in Section 15508(F), that “if there is a hospital or office/outpatient E&M service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the E&M service may be paid.”

Coding E&M with wart removal
Q
When we see a wart or molluscum on the first visit, when we diagnose the condition, can we claim both an E&M code as well as the procedure code for treating it? We have had two consultants give us opposing responses to this question.

A It depends entirely if you did an E&M visit or not.

Simply taking a quick look at the thing in preparation for the removal doesn’t count.

An E&M has to involve getting a history, a review of systems or exam, and medical decision making. If you look at a wart, say “it’s a wart,” and then remove it, it’s a bit much to call it an exam, perhaps.

Still, many payers will bundle the E&M, regardless, which doesn’t mean you should not code it if it’s legitimate.

If the wart removal is completely separate from the E&M - say a patient comes in complaining of shortness of breath but the physician notices a wart on the patient’s back and removes it - you’d add a -25 modifier to the E&M.

Wellness visit with multiple diagnoses
Q
Can a patient have several diagnoses and still be coded as a preventative visit (wellness)?

A Sure. Otherwise a large percent of the population would never get a preventative visit. Assuming the visit truly was a preventative visit, you would list the V code first, then others.

Here are the relevant guidelines:

“During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing, chronic conditions, and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.”

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