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'Directed' Treatment; Defining Separate and Significant


Coding questions? We've got the answers.

'Directed' Treatment

Q: Is this documentation sufficient for a 99214 and a prolonged services 99354 when stated after the full SOAP note: "Spent 25 minutes face to face with the patient performing above evaluation and an additional 30 minutes directing treatment and observation"?

A: I think that is quite succinctly stated and should do just fine. In your case (having read the whole note you sent) it is clear that there were several breathing treatments carried out over a period of time which you have now defined.

You state that you "directed" the treatment. When CPT changed the code descriptions in 2011 from "face to face" to "direct," this would presumably cover "direction," but we can bet that Medicare would prefer face to face for the full prolonged time. Still, your statement certainly meets CPT criteria.

Nutritionist Counseling

Q: One of your previous columns noted that smoking cessation counseling is now covered by Medicare. Do you happen to know if nutritionists can do the counseling and what they are reimbursed for a counseling session? We are looking to hire a nutritionist in our office.

A: The short answer to the first part of your question is yes, if you are referring to codes G0436 and G0437. A nutritionist can bill in his own name and NPI number, if he has one. If he is a direct employee of a physician group, counseling may be billed in the group's name under the general incident-to provisions if supervisory and other requirements are met. If the nutritionist is a hospital employee providing these services in a facility setting, he may not submit a professional charge to Medicare for these services. Look at your Medicare Administrative Contractor's fee schedule to see what the exact payment amount is.

Defining Separate and Significant

Q: In an ER setting, is it appropriate to code an E&M with a 25 modifier if the sole reason for the visit is simple repair of a laceration?

A: That's a maybe. If there is an evaluation service separate and significant from the repair, you can bill it with a modifier 25. Not all repairs will meet this criterion. If you want to get technical, there is likely always an evaluation of some sort, for instance, determining the type of injury, what other structures are involved, what type of repair is needed, etc. But that doesn't necessarily mean it is appropriate to code an E&M. When there is no discussion of other surrounding or related systems, nerves, tendons, vessels; when there is no discussion of concern for anything beyond the repair; then the case for separate and significant is weakened. We often see the language "superficial laceration 'X' aspect 'Y' structure," then, “distal neurovascularly intact,” but again, that does not necessarily take you into "separate" territory.

So the real answer for you is more one of common sense. If you have concerns about damage beyond the obvious, say so. If there is some separate and significant additional work, make sure it shows. But sometimes, just the repair code alone should cover it.

Venipuncture Without an E&M Visit

Q: If a physician performs a venipuncture (CPT code 36415) during the course of an E&M visit, it is our understanding that the venipuncture is not a separate billable service and is bundled into the E&M code. What if a patient has not fasted and needs to come back to the office for a separate venipuncture, which is then performed by the physician and no E&M visit occurs? In this case, should the provider bill the 36415 code?

A: If the patient comes back for the venipuncture the same day, you will probably run into reimbursement issues if the provider bills the 36415 code again. If it is not the same day, you probably won't.

It's not that the venipuncture isn't a billable procedure; it is just most payers' policy not to reimburse 36415 on the same day as an office visit.

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 May 2013 issue of Physicians Practice.

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