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Coding questions? We've got the answers.
Prescription Drug Management
Q: What are the most common codes for prescription drug management?
A: Outside of the pharmacologic management code 90862, which is deleted and replaced by 90863 in 2013, there really are no CPT codes specifically for prescription drug management. The new psychotherapy codes do have a medical management component intended to represent the management of psychoactive drugs. There are codes for various types of infusions, implantations, and different delivery systems - but none only for prescription management.
I assume you are referring to an element of the decision-making component of an E&M code. The E&M guidance section of the CPT manual references the elements of decision making, the third of which is the table of risk. For the actual table go to the 1995 or 1997 Federal Documentation Guidelines. I'm also assuming you are asking whether the "prescription drug management" entry made all use of prescriptions the moderate level or level-four code.
The entries in the first column for low-level decision making seem to reference conditions treated prescriptively: well-controlled hypertension, allergic rhinitis, etc. The entry that causes the most confusion is the entry of "prescription drug management," under the third column of the moderate level. If you're asking whether the presence of any prescription medication qualifies as moderate on this table, payers will reply differently. Some Medicare carriers will say yes, some commercial payers will say no. The prudent course for you to take is somewhere in the middle. For instance, uncomplicated single-system problems treated with antibiotics are more likely low; systemic problems treated with drugs that perhaps require more monitoring are likely more moderate.
These tables were designed to balance each other, they really don't read straight across. You should avoid a "mechanical" reading of them. Make sure all your coding choices consider medical necessity and common sense.
Q: What is required to properly bill CPT code 95951? Is any additional paperwork necessary?
A: CPT code 95951 is billed for each 24-hour period. Since it is a "timed" code, the medical record should document the number of monitoring hours. All timed codes should have the time noted. However, there is nothing in the CPT description indicating that "additional" information or paperwork is required. Look at all documentation as an "itemized bill" of what was done, not as additional paperwork.
Q: I've reviewed the requirements to fulfill the Welcome to Medicare visit. I would like to do my usual health maintenance exam, which we bill as a 99397 and submit the G0402 to Medicare. Our practice is nonparticipating in Medicare, so the patient pays for the noncovered service at the time of service. We file the G0402, and that payment goes to the patient. My documentation covers all the requirements for the Welcome to Medicare visit as well as the health maintenance exam. Does this seem acceptable? I have only done this twice and have not encountered problems.
A: It sounds like you are billing both a 99397 and a G0402 for the same visit. These are both preventive codes, and usually only one is billed. In the transmittal outlining the use of the G0402, G0438, and G0439 the guidance states: "NOTE: Some of the components of a medically necessary [E&M] service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E&M service to be billed for the medically necessary, separately identifiable E/E&M service."
Now I realize this guidance refers to the crossover between a problem-oriented E&M and the IPPE, but in your scenario, you essentially have two preventive service codes with even more duplicative aspects.
Some Medicare contractors have come right out and said that they don't expect both a preventive service (99381-99397) and an IPPE or AWV billed together, or even in close proximity because there is so much crossover.
So to answer your question, I don't think you should be billing both. If you do bill the 99397, it should have a GY modifier.
Q: Can you bill an E&M code for a pregnant patient in her global period if it is a high-risk diagnosis? I read that with our Medicaid you can bill an E&M code for high risk, but what about commercial carriers?
A: The CPT manual section related to prenatal visits states pretty clearly that those visits are for uncomplicated maternity cases. The first statement it makes relating to your question is that, "Any other visits or services within this time period should be coded separately."
That section goes on to say, "Medical complications of pregnancy (e.g. cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes, trauma) and medical problems complicating labor and delivery may require additional resources and may be reported separately."
Now it's nice that the CPT manual says you can report these things separately, but I think what you are really asking is whether Medicaid pays for the separately reported visits. Most states do pay for visits outside the global period or within the overall period, if the diagnosis codes reported relate to the issues listed above. If the reason for the separate service is clear, and all of these services appear medically necessary, it's likely that all of the services will be reimbursed.
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 January 2013 issue of Physicians Practice.