Coding and Documentation

From a CPT perspective, most procedural services include a certain E/M component. So you should not report an E/M code with a procedural service unless the E/M service was “significant and separately identifiable.” If you did the key components of an E/M service in addition to removing the carbuncle, I believe that you could report the code for carbuncle removal as well as an E/M code with modifier -25 attached. Note that “significant, separately identifiable” does not necessarily mean unrelated. As CPT notes, “the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.”

All of the examples cited in the October article correspond to clinical examples given for 99211 in Appendix D of the CPT book. According to CPT, 99211 “may not require the presence of a physician.” This means, from a CPT perspective, the physician does not need to see the patient for this service to be coded. (See the related article on page 39.)

Diagnosis code 203.00 is for “multiple myeloma without mention of remission,” and 203.01 is for “multiple myeloma and immunoproliferative neoplasms in remission.”

The documentation guidelines speak in terms of presenting problems “with or without an established diagnosis.” First episodes of a URI, UTI, etc. would likely be considered a new problem to both the patient and the physician, since they would not be an established diagnosis to either. The second episode would also likely be a new problem, especially when separated by a long amount of time.I believe the term “problem with an established diagnosis” tends to refer either to a chronic condition or an acute condition within a given episode of care. For example, if you had an initial patient visit in which you diagnosed the URI and a follow-up visit two weeks later, then the URI at the initial visit would be a new problem while the same URI at the follow-up visit would be an established problem, since it had been previously diagnosed. If the patient comes back a year later with a new case of URI, it would constitute a new problem.

CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory,” is intended to be reported when the practice incurs costs to handle and/or transport a specimen to a lab. For example, if the practice employs a messenger service to transport a specimen, that service can be coded using 99000. In comparison, if lab staff pick up a specimen at no additional cost to the practice, it would not be appropriate to report code 99000.Code 99000 also is not intended for reporting the obtaining of a specimen. Reimbursement for obtaining a Pap smear or a throat culture is factored into the relevant lab procedure code. Obtaining a blood specimen by venipuncture may be reported separately, using code 36415, “Routine venipuncture or finger/heel/ear stick for collection of specimen(s).”