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Coding questions? We've got the answers
Patients Previously Treated Elsewhere
Question: I am a primary-care physician working in more than one organization. I have a family practice and unrelated employment in an urgent-care center with different provider numbers and tax ID numbers. I occasionally have patients from urgent care who decide to become established with my family practice. On multiple occasions, insurance payers have rejected the 99204 code submitted in the initial visit, stating that the patient is not new because I have treated him in the past three years. Should I be billing for new patients as if they are established in my family practice since I have seen them elsewhere? I have not been successful in appealing these denied claims. How can I make sure I'm getting paid for the work I am doing with patients new to the practice?
Answer: The rule is found on page four of the CPT 2011 Professional Edition. It states, "A new patient is one who has not received any professional services from the physician … within the last three years." So your answer is yes, bill them as established.
There is more language pertaining to tax ID and group in the definition, but your NPI number is showing up on all the claims and you are still you - no matter which hat you are wearing that day.
I can see why you'd want to get paid for these patients as new - setting up the chart, working them up from scratch in the office rather than the urgent-care setting - but you are unlikely to prevail here.
Splitting Technical and Professional Components
Question: We are an FQHC with nine clinic locations doing store-and-forward retinal scans, mainly for diabetic patients. Our scans are taken in one clinic and stored on EyePacs for later reading at our specialist clinic. Each clinic has its own billing NPI number. My question is: Should we be splitting the scan into technical and professional components so each portion is billed under the correct NPI? This could mean we would enter three modifiers: TC, 50, and GQ; or 26, 50, and GQ.
Answer: You are on the right track. To be accurate, and to assign the proper professional and technical components to the actual entities performing or interpreting the tests, you should use those modifiers on code 92250. That code can be broken down into the two components listed above. The modifier rules indicate those elements as well as bilaterally as you have used them. Remember though, any given payer may want the services represented with some arrangement of modifiers (or lack thereof) particular to that payer - there is no one right way to do it.
But you have used them in the way that follows the generally recognized coding principles.
Services Performed by Supervised Residents
Question: I have been working in a teaching hospital setting for many years and was always told that I needed to establish attending "presence" to bill in my name for services performed, in part, by residents under my direct supervision. Now I am hearing that I have to "examine" the patient. Which is it?
Answer: It's sort of both. From 1969 until 1996, the direction in this area was vague and came from a federal publication known as IL372. This is where the "attending presence" language came from.
CMS (then HCFA) has always wanted to be certain that the teaching physician "participated" in the care or management of the patient. If the patient is treated by the resident alone, with the exception of certain primary-care settings, attendings should not bill Medicare for their services.
In 1996, CMS updated the guidance for teaching physicians, and new language came into vogue that included phrases such as, "present for the key portion of the visit or procedure." This was a bit mechanical.
If you look now on the CMS website, you will see a guide to teaching services which gives several examples of "attestation" language describing different types or degrees of involvement. Maybe the most prevalent is, "I saw and examined the patient, agree with the resident's plan as above," followed by something subjective about the patient's condition.
Another, that does not state you examined the patient but indicates involvement, says, "Patient seen and evaluated, agree with the resident's plan as above," etc.
So, the message is the same - establish presence by indicating that you saw the patient and either examined or evaluated him. You have many options now. Good luck!
Prolonged Services Codes
Question: I have heard there is a change to the CPT book that allows me to bill for services on behalf of patients without seeing them. Is this true?
Answer: It's not so much a change in the CPT Manual as it is recognition of RVUs in the Medicare fee schedule that has people talking about code 99358: Prolonged evaluation and management service, before and/or after direct (face-to-face) patient care, first hour.
The prolonged services codes 99354-99357 represent additional face-to-face time spent with a patient in the office or inpatient setting. These codes have long been payable services and the only issue with them is whether providers recognize that they've done the related services and document that extra time.
99358 on the other hand, has been somewhat ignored because it did not have any RVUs in the Medicare fee schedule and was thus not payable by Medicare. Consequently, many other payers followed suit.
The 2011 fee schedule, however, gives a work RVU of 2.10 to 99358, giving it roughly the same RVU as a 99215 office visit or a 99233 inpatient follow-up. It still is not necessarily payable by Medicare carriers, and may not be payable by some commercial insurers. But it has a recognized value.
Recently, 99358 has been used by providers who spend extensive time reviewing medical records for complex patients in outpatient settings. The provider can't calculate an E&M based on time, because it's not face-to-face with the patient. But the provider can use 99358, and that is the example of its use given in the CPT manual. The manual states that this type of prolonged service can be reported on a different date than the primary service, as long as it relates to a recent or upcoming direct patient visit.
Another reason this code has received attention recently is that the CPT removed the add-on code designation. In the past, 99358 needed to be reported the same day as the primary E&M. Since that is no longer the case, 99358 has much greater flexibility.
Billing for Consults
Question: What code do we use when a patient comes to the ER with abdominal pain, the ER doc calls a surgeon to evaluate the patient, and the patient is admitted and has surgery the next day? Can the surgeon bill insurance for the ER consult?
Answer: If the question is: Is this a consult? The answer is yes. The ER is requesting the opinion or advice of the surgeon in regard to the abdomen. That part is easy.
The next part may not be. It depends on the patient's insurance type. Medicare and most of its derivatives don't pay for consults. In the outpatient setting (ER) you need to crosswalk the consult to the equivalent office visit code.
You still should check with commercial insurers to determine if they cover consults. Your billing staff should have some idea which insurers in your area pay and which insurers don't.
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 October 2011 issue of Physicians Practice.