CODING & DOCUMENTATION

CPT defines “face-to-face time” in office and other outpatient visits as “only that time that the physician spends face-to-face with the patient and/or family.” This includes obtaining a history, examining the patient and counseling the patient. When reporting face-to-face time with a patient in the hospital, the definition is extended to include unit/floor time (the time the physician is present in the patient’s hospital unit, including at the bedside rendering services for that patient). This includes time spent reviewing the chart, examining the patient, writing notes and communicating with other professionals and the patient’s family.CPT recognizes that physicians in the office also spend time doing work before or after the face-to-face time (e.g., reviewing records and tests, arranging further services and communicating with other health professionals). This non-face-to-face time is not included in the typical times that appear in the CPT descriptors. However, the reimbursement you receive from Medicare for these visits does reflect pre- and post-encounter work. It is included when calculating the total physician work associated with each code under Medicare’s resource-based relative value scale.Note that Medicare only accepts face-to-face time with the patient or the patient and family. Medicare coverage of situations where the physician meets with the family alone is limited; see the Medicare Coverage Issues Manual section 35-14 for details (cms.hhs.gov/manuals/06_cim/ci35.asp#_1_15).

No. Generally, when an NP or physician assistant (PA) sees a patient in a physician’s office, he or she should use the usual office or other outpatient visit codes (99201-99215). There are different requirements for billing if the visit with the NP or PA is going to be billed under the NP or PA’s name rather than under the physician’s name. For more information, see “The Ins and Outs of ‘Incident-To’ Reimbursement,” November/December 2001, page 23.

In the case of Medicare, there is an HCPCS code, M0076, for prolotherapy, but it is not covered by or valid for Medicare purposes. Referring to prolotherapy and certain other therapies, the Medicare Coverage Issues Manual states that “the medical effectiveness of the … therapies has not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they are not reasonable and necessary as required by 1862(a)(1) of the law.” If you want the Medicare patient to pay for the service himself or herself, you must execute an Advance Beneficiary Notice prior to the service.There is no CPT code designated for prolotherapy. To the extent that prolotherapy involves the injection of a ligament or tendon, you may be able to submit 20550, “Injection; tendon sheath, ligament, ganglion cyst,” for this service. (Note that in CPT 2002, 20550 has been revised and related new codes have been added; see “CPT: What’s New in 2002?” January 2002, page 16, for more details.) However, if other payers also consider prolotherapy to be investigational, use of 20550 may be misleading and result in payment for otherwise noncovered services. Thus, you should contact your third-party payers to determine how they want the service coded or use the unlisted procedure code 20999 with a description of the procedure clearly indicated on the claim.