CODING & DOCUMENTATION

If the visit was scheduled at the request of the physician, you can report 99211. If the visit was prompted by the patient, you can code 99211 if there are clinical indications for the visit. For example, if in the process of having his or her blood pressure checked the patient reported dizziness and a headache, prompting the nurse to take additional history and talk with the physician, it would be appropriate to code 99211.An encounter with a stable patient who decided to come in for a blood-pressure check simply because he or she happened to be in the neighborhood would not ualify as a level-I visit because the physician did not order the service and there were no clinical indications to warrant it.

CPT code 96110 may be reported separately in addition to a preventive medicine service only when a structured developmental testing tool (e.g., Ages and Stages or the Parent Evaluation of Developmental Status) is used to assess the patient's development. Modifier 25 should be appended to the preventive medicine service code to indicate that the work involved in providing the preventive medicine service was significant and separately identifiable from that of the developmental testing. Not all payers will separately reimburse this service on the same date as a preventive service visit.

Code 97116 is used to report gait training therapy. Some insurers pay for this code only when it is used by physicians or physical therapists or when a minimum time of service is met (e.g., at least 8 minutes). Check with your payers to learn their individual policies. If the patient is a Medicare beneficiary, make sure that you are meeting the requirements outlined in Chapter 15, Section 220.2 of the Medicare Benefit Policy Manual.

If a National Coverage Decision (NCD) has been made by Medicare for a laboratory test, the NCD Coding Policy Manual is a good source for information – not only on covered diagnosis codes but also on frequency of coverage. The latest version of the manual is published on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov/coveragegeninfo/04_labncds.asp.

No. If you code based on key components, you do not have to meet the average times noted in CPT. Noting the time of service can be helpful because, if counseling and coordination of care end up dominating the face-to-face time spent with the patient, you might choose to code the visit based on time (see “Time Is on Your Side: Coding on the Basis of Time”).

The global period assigned to code 10061, “Incision and drainage of an abscess; complicated,” is 10 days. Postoperative care such as repacking and dressing changes is not separately reportable within that 10-day period. If postoperative care is necessary after 10 days, those services should be separately reported, with no modifier required.If the care provided significantly exceeds the typical service, it is possible to add modifier 22 to the surgical code, provide information on the extenuating circumstances and increase the billed amount by a percentage that you feel is equal to the increased work and expense. Your payer won't necessarily provide the additional payment, but it might be worth a try. Note that if the procedure has already been billed, you may need to submit a corrected claim for this purpose.

Though the triage room is open and staffed 24 hours a day, this does not make it an emergency department. It is an outpatient setting for which codes 99212–99215 could appropriately be used to report services. Place of service code 22, “outpatient hospital,” should be reported as well.

Code 99058 is to be reported in addition to the code for an emergency service provided in the office that disrupts other scheduled office services. If the migraine required such immediate attention that the physician interrupted the care of scheduled patients to provide care to this patient, reporting code 99058 may be appropriate. Many payers including Medicare do not pay separately for code 99058, so you may wish to check payer policy before adding this code to what would already be an unusual claim for two unrelated E/M services on the same date.

It sounds as though you're on track. According to CMS, the remittance advice associated with a claim containing a PQRI quality code line item will include N365 as a standard remark code and this message: “This procedure code is not payable. It is for reporting/information purposes only.” This remittance advice will confirm that the quality-data code has been captured by CMS for PQRI analysis.

The physician administration, interpretation and written report associated with the MMSE is included in the E/M code for the patient encounter and cannot be billed separately. The 1997 version of Medicare's Documentation Guidelines for Evaluation and Management Services indicates that “brief assessment of mental status including: orientation to time, place and person; recent and remote memory; mood and affect (e.g., depression, anxiety, agitation)” is one of the exam elements for a general multisystem exam.