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Who Can Perform the AWV; Coding for Urea Breath Tests


Answers from our coding expert on questions regarding the Medicare Annual Wellness Visit; urea breath tests; counseling time; and consultations.


Q: Can licensed practical nurses (LPNs) perform the Medicare Annual Wellness Visit (AWV)?

A: No, not entirely on their own. Let's look at the exact guidance provided by Medicare in Transmittal 2159:

B. Who May Perform

"The IPPE and the AWV may be performed by a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Act, by a qualified NPP (nurse practitioner, physician assistant or clinical nurse specialist), or for the AWV, by a health professional (a medical professional including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals who are working under the direct supervision of a physician. The contractor pays the appropriate physician fee-schedule amount based on the rendering National Provider Identification (NPI) number."

That guidance was further clarified in various Medicare contractor publications that state that AWV elements are a "collaborative" effort, not performed only by nurses and not necessarily performed only by physicians. The idea is that the appropriate level of staff can participate toward various components. An LPN for example, can take vitals and record elements of the history and other information. A physician, however, must review the information, and one would expect the physician to review it with the patient.

The keywords really are, "under the direct supervision of a physician." The AWV is a professional service billed in the physician's or NPP's name, and the physician or NPP is responsible for it.


Q: Can a physician working in a hospital bill CPT codes 78267 and 78268? These are the urea breath test technical code and the urea breath test analysis code.

A: The red flag here is that this is occurring in a hospital. Per the Medicare Physician Fee Schedule, these codes are not physician services. They do appear on the lab fee schedule for some Medicare contractors. Like most lab services, 78267 and 78268 are technical services, and they should be billable by the hospital, not the physicians. The "analysis" referenced in 78268 is the work of the machine, not the physician. The physician interpretation should likely just be a point in the Medical Decision-Making Table B, not the charge for the technical service of analysis.


Q: I see a lot of patients who I believe require an Ankle Brachial Index (ABI) Doppler, code 93922. I also think that most of these patients would justify a 99214 visit. If I based the code on total time spent, it would be a 99215. Here's my reasoning:

If a 99215 is 40 minutes, that would give me 20 minutes to do the test and discuss medical issues. I would spend the other 20 minutes counseling the patient regarding all diseases including the ABI test result. Of course, the counseling would occur during the entire visit, but I think it is reasonable to say half of my time would be spent on counseling. Is that OK?

A: In terms of the E&M visit, the time it takes to perform a billable procedure has to be backed out of the total time. Don't start backwards from "a 99215 is 40 minutes."

Instead, start with: I did some E&M/visit services, a procedure, and then some more E&M/visit services. What is the total duration of the non-procedural work?

In the case you lay out above, it sounds like both the visit and the procedure total 40 minutes. Given that the procedure takes some amount of time, there is no way that the total non-procedural time would equal 40 minutes. Therefore, over half of the visit wouldn't be counseling, so it wouldn't meet the requirements for a 99215.

Whether the E&M is going to be a 99213 or 99214 will depend on how long it takes you to perform the procedure.

If you tweak the times around to get the 99215, given the initial outline above, I would have concerns.


Q: I work with an infectious disease group. We are called for consultations for patients in an observation stay in a hospital. We currently bill 99205 or 99204 (this includes some outpatient services prior to a formal admit), and use place of service 22, observation. We sometimes have problems getting an authorization from the primary-care physician, and with getting paid by the insurer. The insurers have said that we are billing incorrectly and should use codes 99218 to 99220. But these codes specifically state that they exclude services by physicians other than the admitting physician, and we are never the admitting physician. I also think those codes are for the facility. Are we billing correctly?

A: You have a few questions here. I can't address the difficulty you have obtaining authorizations from other physicians, however, I can attempt to provide you with some billing guidance.

You stated that you are called for consultations for patients on observation in the hospital, then you said that your 99204 or 99205 code includes some of the pre-observation outpatient services. This is somewhat contradictory.

If the patient is seen in an outpatient setting not located in a hospital, (i.e., a clinic or your office), then you should bill place of service 11. This is consistent with codes 99201 to 99205.

If you are seeing the patient in a hospital clinic, then you should use place of service 22 for hospital outpatient. This is also consistent with codes 99201 to 99205. You can also use place of service 22 to describe the observation setting, and this could include codes 99218 to 99220 and codes 99224 to 99226.

Whether the patient is in your office, a hospital clinic, or an official hospital observation area, the consult codes 99241 to 99245 are appropriate, but these cannot be used for Medicare or other governmental payers or programs, as you likely know.

Your role in patient care is another factor to consider. If you are being asked to provide an opinion or advice as to the patient's condition, that is consultative in nature. When possible, use the consult codes as above. These would apply to the first office/clinic visit, or the first visit in an observation session.

For subsequent visits, if the patient is indeed in an observation setting in a hospital, then you should use the observation subsequent care codes 99224 to 99226, with place of service 22.

If you are not the admitting physician then you are correct, you would never use the 99218 to 99220 codes.

I'm a bit surprised that anyone would give you a hard time about 99204 or 99205 in either the office or place of service 22. There's nothing unusual about it.

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 February 2015 issue of Physicians Practice.

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