In-Tandem E&M Service; Coding to the Bell Curve

April 4, 2014

Get coding guidance on group visits for asthma, review of care plans, coding for ventilation services, and more.

Group Visits for Asthma

Q: My office wants to run a pediatric asthma education clinic with six patients together as a "group." A physician will do the triage, history of present illness, review of systems, and physical examination. Then a nurse educator will show a 20-minute video about asthma triggers, use of rescue medication such as albuterol and proventil (inhaled steroids), and an asthma action plan. The total time of the visit is probably 45 minutes to 60 minutes.

Can we bill a 99214 with modifier -25 and 94664 for this? Can we do group visits based on time for counseling, education, and coordination of care with the medical assistant or registered nurse? Or, does it need to be based on face-to-face time with a physician?

 A: Similar scenarios arise from time to time with different specialties and disease-specific orientation. From your perspective, it is likely a question of efficiency - more birds with one stone so to speak. The broader issue is whether you bill for individual patient services when part of the service is more of a group service.

There are group and individual counseling codes such as 99411 and 99401, but these are largely preventive in nature. And as you might expect, they pay less than individual problem-oriented codes do.

Your question suggests that the individual history and physical exam is performed by the physician, then some, perhaps larger component, is turned over to the staff for more common educational elements.

In regards to whether you can bill some portion of this by time, and whether the support staff can contribute to this, that answer is fairly clear. The time spent in counseling in the outpatient setting must be face-to-face with the physician, not ancillary staff.

If there is a discrete physician component that includes the history, physical exam, and some medical decision-making, then you have a case for the 99214. The decision making would need to be of moderate complexity, however. If it isn't, and the physician doesn't personally provide the counseling, then you really can't support a 99214 considering medical necessity.

If you bill a 99213 and then try and bill a counseling code, you'll find that most payers will only pay one of these on the same day. The components as you lay them out above seem most reasonable, and a good use of time by all, but the coding and billing rules don't mix and match some of these components as easily. You can bill the E&M codes with 94664 and the modifier -25 as you indicate, and there does not seem to be a bundling issue with 94664 and the counseling codes.

The best bet from both an efficiency and reimbursement perspective might be to do the individual aspects of the visit as normal office visits, which could include some counseling. Then, suggest that patients attend a group session for further instruction. The latter could be billed with the group prevention type codes and the 94664, but the physician would have to participate meaningfully.

In-tandem E&M Service

Q: Our doctor went to an outpatient infusion center at the hospital and ended up doing a full E&M for a patient so that the patient would not have to walk across the street after chemo completion. What set of codes would the physician use for that service? 99211-99215 with a place of service hospital or ambulatory care unit? The physician also asked where the dictation should be: on the hospital record or the office record?

A: The short answers are yes and yes. Use the regular "outpatient or other ambulatory facility" codes 99212-99215 depending on the level of intensity, and use the hospital outpatient POS 22.

It doesn't really matter from a billing perspective where the documentation is, but the physician probably wants to scan or send a copy to his EHR if he uses the hospital system, and he should copy ("cc") himself when he scans or sends it.

Coding to the Bell Curve

Q:  My office manager told me that, even though my office visit "curve" or profile is almost up to the levels of the Medicare family medicine profile, I am still coding too low. Is that possible?

A: You may have a smart office manager. If you are talking about the latest (2011 Part B Medicare Utilization) curve that shows 47 percent 99213s, 42 percent 99214s, and 3 percent 99215s, then your office manager is probably right. These curves contain tens of millions of encounters for all providers using a family medicine taxonomy code during calendar 2011. This includes teaching hospitals and providers in heavily capitated environments. Both of those circumstances tend to over-report 99213s (usually at the expense of 99214s). Remember too, that these are all providers averaged together (good coders, undercoders, and overcoders).

Having spent some time in family medicine circles, I can tell you that the tendency is to undercode. So even if you match up exactly with that profile, you are probably undercoding some. One indicator that the Medicare profile doesn't necessarily reflect patient acuity and work is the 42 percent 99214. 99214 is indicative of moderate complexity, and that is typically either three stable chronic problems, one stable and one worsening, or a new problem with a significant differential. Don't most Medicare patients fit into those categories? Then why are only 42 percent 99214s and 47 percent the lower complexity 99213s? It's probably due to bad coding.

Your real benchmark should be based more on who your patients are. A good rule of thumb is to consider your Medicare, Medicaid, and indigent percentage of payer mix. That is the area that should be under the 99214 and 99215 portion of the curve. It's true that some of these patients will present for lower-level problems, but these will be offset by commercial patients with more significant issues. The benchmark just works. Try those numbers on after you start coding correctly.

General internal medicine, you also tend to undercode, so take heed.

Coding Ventilation Services

Q: What do I need to document to support the vent management codes in a hospital?

A: Procedure codes 94002 and 94003 apply only to hospital care for critically ill patients. They do not apply to routine recovery room ventilation services.

Use ventilation assist and management and initiation of pressure or volume preset ventilators for assisted or controlled breathing first day procedure code 94002 when respiratory support must be established for a patient. This is a one-time charge per hospitalization that is paid when the claim documents that a respiratory problem exists (for example, respiratory distress, asphyxia). After the first day, use subsequent days procedure code 94003. Label the note "Ventilation Management," then indicate the settings and values, the diagnosis, and a legible signature.

Other support service charges billed on the same day as ventilation support are usually denied (e.g., arterial or venous punctures, interpretations of arterial blood gases, pulmonary function tests, and management of the hemodynamic functions of the patient).

Review of Care Plans

Q: What is your insight into E&M billing for patients that return for test results (echoes and/or nuclear studies)? We call patients to relay lab results or Holter results, but when it comes to echoes and nuclear testing, the physician needs to have a face-to-face with the patient to discuss the results, even if the results are normal. Patients have questions regarding their symptoms. Generally, this face-to-face visit results in ordering more tests or changing medications. Should we bill for office visits that are for test results and review of care plans?

A: Absolutely bill for those visits. Bills should typically be based on the time spent counseling the patient. That's what the coding by time versus coding by components version of E&M coding and documentation is designed for: Visits that don't fit into the normal history, exam, and decision-making model. I'll bet those visits start out with a comment like "patient here to discuss test results..." If so, at the end of the note, in the A/P section, state that "over half of a 30-minute visit" or "all of a 20-minute visit" was spent discussing treatment options, etc. That's what the time angle is for!

Fetal Non-stress Test

Q: Is it appropriate to bill an E&M in the following situation: In an outpatient setting, a pregnant patient comes in for a 59025. Telephone orders are read back to the OB, but there is no physician present and no physician progress note?

A: No. If all you are doing is interpreting the fetal non-stress test, then that is all you bill. You can't have an E&M visit without a physician in the office.

Scenario Stumped

Q: I have four scenarios that I need your guidance on.

Scenario 1: A patient is seen in the ED by a pediatrician. The pediatrician assumes care of the patient and the patient is sent home, not admitted. What should we bill for the pediatrician?

A: If the ED physician sees the patient first, and the pediatrician is the patient's physician, bill 99212-99215.

Scenario 2: A patient is seen in the ED by a pediatrician. The pediatrician assumes the care of visit and the patient is admitted. What should we bill for the pediatrician?

A: The pediatrician bills an admit code.

Scenario 3: A patient is seen in the ED by a pediatrician. The pediatrician is called in for consult and the patient is sent home. What should we bill for the pediatrician?

A: The pediatrician bills a 99241-99245.

Scenario 4: A patient is seen in the ED by a pediatrician. The pediatrician is called in for consult and the patient is admitted. What should we bill for the pediatrician?

A: The pediatrician bills an admit code.

Payment for What You 'Will Do'

Q: For Table B on the E&M decision-making tables, would it count as two points if a provider plans to discuss a case with another provider but he has not already discussed the case with another provider? Also, if a provider discusses with a mental health caseworker whether Medicare will pay if the provider refers a patient for mental health treatment, would that count as a discussion with another healthcare provider?

A: The tables say exactly what they say for a reason. Whenever you kind of "stretch" them to include something different, even something slightly different, you run the risk that a payer will interpret it differently. So the answer I offer is my opinion, it's not authoritative.

That said, on one level I'm sure that what you "will do" isn't intended to be included in today's payment. Then again, when you order labs in the data table, the "interp" will happen later, so there's an argument for it. But my inclination is that you should not include things that "will" happen.

On the next question, if the discussion is clearly about payment, I think it would be pretty poor form to try to bill that as "discussing the case with another provider." If the discussion is about the appropriateness of the transfer or the care, however, that would count as a discussion.

Tough questions. No real answers, just opinions!

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at billdacey@msn.com. He will help clear up the confusion, and you may even see your question featured in the journal.

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.

This article originally appeared in the April 2014 issue of Physicians Practice.