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Coding questions? We've got the answers
Face-To-Face Visits for Reviewing Blood Work
Q: One of my physicians wants to bill a 99212 for a patient to come into the office and have infertility blood work drawn. The nurse would bring the patient back, find out what they are here for, do any workup required and take them to the lab for a blood draw. Once the results are back in, the physician will review and in these cases, there is always contact with the patient and plan of care/RXs for treatment. The physician feels like this is above the normal review of lab results, where the nurse contacts the patient with results, phone line notification, or card mailed. There is no doubt to me that the complexity of the problem and MDM is there for a 99212 but does the patient have to have a face-to-face with a provider to bill this code or does the review and coordination of follow-up care meet the requirements?
A: We get questions like this a lot! The short answer is that the physician needs to see the patient, face-to-face. 99211 is the only one that works as the "nurse visit." If that weren't the case, we'd have a collection of services of escalating complexity all being "done by proxy" by the physician through the nurse. The line is drawn between levels 1 and 2.
Medicare Annual Wellness Visit
I have a bunch of questions that relate to the new Annual Wellness Visit (AWV) codes. Does anyone have answers for these yet?
Q: What does "medical professional" mean? Who can perform the AWV? Can I hire an LPN just to do these?
A: See page nine of Transmittal 134: It clearly states who a medical professional is. It seems to leave the door open for some "incident-to" type services such that a nurse or someone without an NCI could perform these services. Indeed, the Medicare Administrative Contractor (MAC) WPS has said that these services can be carried out by an LPN under direct physician supervision, present in the office suite, and CMS in Baltimore has said that these were "intended to be collaborative." That said, I would get something in writing from your local carrier or MAC before I went down that road.
Q: How can we determine the patient's eligibility for the AWV? There is mention of a 271 Eligibility Response transaction report that can determine when patients first became eligible for Medicare Part B, when they had their Initial Preventive Physical Exam (IPPE), and when they are due for their AWV and subsequent AWV. We need to determine that before any patient can be scheduled for an AWV or an IPPE.
A: This is almost an internal registration question or as you point out you can get the answer from your carrier via report. Your real-time issue is whether or not the patient has had an IPPE before and when. Contact your carrier about the 271 report - they have the answer!
Q: By what date do we have to be in compliance with the AWV requirements?
A: When you bill any of these codes you must meet their criteria - documentation compliance is linked to filing the claim.
Q: Can a provider provide Preventive Medicine Services (99381-99397) instead of an AWV or in addition to an AWV on a different date? Since the AWV does not include a detailed review of systems or a comprehensive physical examination, those two aspects of the annual physical/preventive service (99381-99397) that are provided to non-Medicare patients will not be provided to Medicare patients during the AWV.
A: Technically yes, although I don't know why you'd want to - it isn't covered and you'd really tick the patients off. CMS officials recently said they would not expect to see two separate preventive services on the same date as there would be too much overlap.
Q: Is the vision exam that is required by the AWV a covered service under Medicare?
Do we bill for the vision exam? Do we get paid for it?
A: The vision exam is mentioned in the IPPE, not the AWV. Code 99173 has an extremely low (.07) RVU and is likely not paid separately with any E&M. 99173 is covered by Medicare, it's just limited coverage meaning it can be upstaged by a higher RVU service which it usually is.
Q: The advance care planning is optional. Do we want to include it as part of the AWV form?
A: Most people do. It's part of Medical Home and other quality-oriented programs. It seems a prudent thing to do, and planning is certainly a good thing; it could save the system a lot of money. It has been removed as a requirement - I think the government would appreciate it if it were done however.
Some other questions you might want to ask are:
1) Do we give the patient a copy of the personalized preventive plan? The IPPE requires that it be shared with the patient, the AWV does not specify this.
2) Exactly what risks do we detail? Everyone talks about depression and falls, what else is important?
3) Have you looked at the USPSTF recommendations? There is federal guidance well beyond the transmittals. How many providers have gone the extra mile and looked up the details?
Level 5 Cases
Q: I have a doc that is part of a pediatric cardiology practice and is arguing that basically all his cases are level 5's. The reasoning behind it is that he feels his risk level (table of risk) is always high because the children are coming in with a presenting problem of an "acute illness that may pose a threat to life or bodily function" (e.g., chest pain, fainting episode, f/u of patent ductus arteriosus, abnormal EKG). He is doing a lot of testing (EKG, Holter, echo, pulse ox) and is adamant that each patient is treated as if they could die from a cardiac issue, hence the high risk.
So our question is when you are determining a level in the Table of Risk, are you judging the problem after the patient has been seen and nothing came of it (chest pain, ruled out to musculoskeletal), or are you taking into account the risk involved when the patient presents (chest pain)? What is your take on this?
A: You are basing your risk assessment on the pre-results risk and differential, the risk of the presenting problem (and its potential) while at the same time counting the "further workup planned" bit from the back end of that same visit.
I share your concern for any provider who states that "all" his visits are "always" level 5 - that should raise some warnings - but based on the example you gave it seems reasonable that many or even most could be fives. At the end of the day, each one is an individual case and needs to be regarded that way.
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 email@example.com or firstname.lastname@example.org.
This article originally appeared in the June 2011 issue of Physicians Practice.