Coding questions? We've got the answers.
Q: Do I use the 58300 code or the J7302 code for IUD insertion? A payer sent me a fee schedule as part of the contract and it does not have IUD insertion code 58300. It does, however, have code J7302, the code for the Mirena (Levonorgestrel) IUD Insertion. Have I been using the wrong code (58300) all these years? How can I remember codes by payer?
A: The 58300 is the right code unless a payer specifies otherwise. In this case, the payer seems to want the J code.
To the second part of your question, getting into payer particulars is probably not the best use of a physician's time. I believe physicians should pick the CPT code, and the billing/charge acquisition staff should make any payer-specific changes. Your office or institution, however, may have different policies. I'd recommend physicians ask if they can stick with the CPT basics and let the coding/billing staff make changes as needed.
Established Visit Components
Q: I have been looking for a Medicare statement that says: "When coding an established visit, one of the two key elements must be the medical decision making (MDM)." I saw a previous coding column in which you mentioned this rule. Does Medicare have a written statement on this?
A: I am aware of no statement that specifically states that MDM needs to be one of the two elements when coding an established visit. What I have long referenced, however, is the Medicare capstone statement that "Medical necessity is the overarching criteria for payments made..."
MDM (the number, type, and acuity or severity of problems) is the E&M component most closely linked to medical necessity, which is why the MDM component assumes a dominant role among the components of an E&M.
Not using MDM as one of the two components in an established E&M would allow the extent of history and exam to dictate the overall code. In the case of pediatrics, for example, it is common to do a comprehensive exam on almost every visit, and the medical history component is also frequently comprehensive. The MDM component acts as an anchor to keep the encounter rooted in medical necessity. In the worst case, a provider could take a comprehensive history and perform a comprehensive exam for a minor bump or bruise.
Medicare has actually stated, however, that it will pay based on what it perceives the problem requires, not necessarily based on what a provider does.
Several federal regulations mention the concept of necessity, and one mentions medical necessity specifically as opposed to the "volume of documentation" in a given note. For instance, an excerpt of one of the Medicare online manuals states: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."
The volume comments have arisen as more practices implement EHRs. Even if a note is heavy on history and exam elements, the overall code must consider medical necessity.
Vaccines and E&M
Q: If a patient comes in for vaccinations only, and the doctor gives the vaccines, do I only bill the vaccines that are given to the patient or can I also bill a minimal office visit since the doctor gave the vaccines?
A: If an injection or service is the primary purpose of the visit, and that is all that is done, then that is all that should be billed. In this case, you should bill the administration of vaccine codes (90460-90474) and the CPT codes for the vaccination supply itself (90476-90749). Unless other services are provided, no E&M should be billed.
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 November/December 2013 issue of Physicians Practice.