Complexity and Comorbid Disorders; Improving 99213 Documentation

April 8, 2013

Get medical coding guidance on complexity and comorbid disorders; improving 99213 documentation; shave lesion codes; remote IV infusion and more.

Complexity and Comorbid Disorders

Q: I have a question regarding medical decision making (MDM). In the context of seeing a patient for a specific problem - from a specialty perspective, whether it's psych or renal - and my prescription focus is one diagnosis; when estimating the complexity can I still take into account all the comorbid disorders?

A: The MDM is the overall best indicator of the code level, and it is really more important than the other components of history and physical examination, as it is tied to medical necessity. Within MDM, you need to meet two of three subcomponents, of which risk is one. Most often, it is the first table (the number of diagnostic and treatment options) and the third table (risk) that creates the overall MDM.

The first two tables are somewhat quantitative, the table of risk requires more nuanced language (i.e., how sick someone is, how bad the problem is, etc.). So the table of risk is not necessarily more important than the other two, but it could best characterize the level of decision making.

Medicare has stated: "Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent, and risk to the patient) was affected by comorbidities or chronic problems listed." In the A/P area, include a separate line to address this. Write something like, "Problem A in the setting of X," and use words that describe complexity, interaction, etc. I hope that helps.

Improving 99213 Documentation

Q: I billed a well visit and a 99213 and my office manager said I couldn't bill the 99213 because I didn't have an HPI. I treated the patient for high cholesterol and there was a lab finding, but the patient could not be expected to have a physical complaint for an HPI, unless I listed the lab finding in the HPI. How can I better document?

A: You pretty much have the answer in your question. Document the HPI just as if it is a standalone 99213. For lab results in the case of lipid management, you could state the severity (LDL, HDL values), the meds they were on, even how long this issue had been going on. That's plenty of HPI elements for a 99213.

Your question leads me to wonder, however, whether you are just mentioning the patient's labs in the context of the preventive session. Was this visit, in part, about managing the problem? If so, you need to make an HPI to support both codes. It's easy in a chronic disease follow-up visit when you can give the statuses, but it's a bit less obvious in the case of a preventive visit.

Shave Lesion Codes

Q: I have a provider that consistently documents the word "saucerization" when doing small lesion removals. He says that they are best coded with the shave lesion codes, but couldn't they be coded as excisions?

A: An excision by CPT definition is "through the dermis," meaning you are into or up to the subcutaneous layers. It sounds like the provider is being precise in his coding. Go with him on this one.

New Medicare Codes

Q: I was told that I do not need to see a patient to use the new Medicare transitional care management codes. Will the care coordination activities without a face-to-face office visit suffice?

A: When Medicare proposed its own G-codes for these types of services, it did not require a visit. In late 2012, it decided to adopt the new CPT version of the codes that do include a visit. So yes, you now need the visit and the other communication and coordination elements.

Remote IV Infusion

Q: My doctor wants to use CPT code 96416 for billing remote oversight of home IV infusion for chemotherapy. Is this the right code?

A: The CPT and Medicare code description make it clear that this code is not for use by physicians in the facility (hospital) setting. There is no discussion of this service in the larger service descriptions that reference home prolonged infusion of chemotherapy.

The CCI edits make it clear that 96416 is a component of all the home visit E&M codes, 99341-99350, and cannot be billed separately.

The relative value of the code in the 2013 Medicare Physician Fee Schedule is 4.19; the work value is .21; the physical exam is 3.91; and the malpractice is .07. Since the physical exam component reflects the overhead component of an office, and this is in the home, the only factors that apply are the work value and malpractice. These make up about 5 percent of the total RVU. Since the Medicare payment amount is approximately $167, 5 percent is about $8. So even if your provider is present in the home, she is far better off billing a home visit than trying to bill a portion of 96416.

CPT codes 99601 and 99602 represent home infusion services for the first two hours and each additional hour, respectively. Some Medicare Administrative Contractors do not have RVUs for these codes and don't pay them.

Your question seems to be more about remote management of these services and not code 96416. Have you looked at the new complex chronic care coordination services codes? If you are doing significant remote management these may be an option.

 Time Changes

Q: Back in January of 2012, you wrote about a change to the way time could be counted for E&M counseling. Has there been any more written about that?

A: What you are likely referring to is when we pointed out a distinction between "typical times" versus "actual times" that first appeared in the 2011 CPT book introduction. It was the first time we'd seen that distinction. The additional sentence remains in the 2013 CPT manual. It reads: "When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used."

The CPT manual has not amplified or commented on that section since, but there are indications Medicare believes its version of time is the more conservative "typical time" stated on each E&M code where time applies. I would give that some thought.

The 2013 CPT manual does, however, go into greater detail on time in its new section on psychotherapy codes. For instance, it states: "In reporting, choose the code closest to the actual time (i.e. 16 to 37 minutes for 90832 and 90833, 38 to 52 minutes for 90834 and 90836, and 53 minutes or more for 90837 and 90839)." The three sets of codes referenced have typical times of 30, 45, and 60 minutes respectively. So CPT does seem to be developing this concept with increasing granularity. As a result, it would seem increasingly reasonable to employ the "closest to typical time" approach. Glad you asked!

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 certified coding 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 April 2013 issue of Physicians Practice.