Who Can Bill Advanced Care Planning Codes?

December 8, 2016
Bill Dacey

This month's coding column is about whether or not one or more physicians of different specialties can bill the advanced care planning codes.

Q: Can more than one or more physicians of different specialties bill the advanced care planning codes 99497 and 99498? Or is it just the primary care?

A: Yes, whoever does it and documents it can bill it. The payers may not want to see more than one of these services from different providers on the same day, but there are no frequency or specialty limitations.

Q:  I have question regarding billing E&M services with injection in office (20610). We have been getting denials for these indicating "separately identifiable evaluation & management service cannot be verified" or not separately reimbursable. Do you have any information on this?

A: The question here is whether or not there really is a separate E&M documented. If you have notes that that say 'here for injection' you'll lose any appeals on these, but if there really is a problem that has to be assessed prior to treatment, and it is well-documented, you should get the additional E&M paid. Remember that most insurers pay these 'modifier 25' claims when billed if there is adequate documentation of both services, but many will request that documentation or deny the first claim on a regular basis. Your success here will be largely contingent on the quality of your documentation.

Q: I would like to bill an ER visit for my work in the labor and delivery area of the hospital. The labor and delivery triage unit is really just an extension of the ER for patients who are above 20 weeks. When patient's above 20 weeks present to the ER, they are sent to us even if they come from registering in the ER. Can we use the ER codes?

A: Per the CPT manual, the ER codes 99281-99285 represent services provided in an emergency department, in a facility setting that meets the definition of an ER. I'm sure that your labor and delivery area does meet the criteria of being open 24 hours a day and is prepared to take unscheduled patients at risk - but your real answer here will come from the hospital.

The hospital or their legal department would be able to tell you how that area is classified or what it supports. Is it a designated observation area, a wholly outpatient setting?

Theoretically you could bill outpatient codes, observation codes, same day admit discharge codes, consult codes or even hospital admit codes in that setting. ER codes are unlikely, but possible. Check with the hospital's legal department.