Fam Pract Manag. 2003;10(2):23
“Status” of a chronic disease
In the documentation guidelines, what constitutes “status” of a chronic disease, and how should it be documented (e.g., “pt has diabetes, hypertension, high cholesterol,” or “pt has well-controlled dm on X with glucoses X, etc.”)?
The documentation guidelines don’t address your point specifically, but some indication on your part as to the current nature of the patient’s chronic condition is, if not required, certainly more in keeping with the spirit of the guidelines (“status” = “well-controlled” in your example). Simply documenting that the patient has diabetes does not say anything about its status. If applicable, you may also want to indicate how chronic conditions relate to the presenting problem.
Anoscopy & E/M
Can I submit a code for anoscopy (e.g., 46600, “Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)”) in addition to an evaluation and management (E/M) service?
Yes, as long as the E/M service was significant and separately identifiable. According to CPT, “The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.” You may need to add modifier -25 to the E/M service to indicate that it was significant and separately identifiable. Also, be sure to clearly document the level of E/M service reported in addition to the performance of the procedure.
Pulse oximetry & E/M
Can I submit a code for pulse oximetry (e.g., 94760, “Noninvasive ear or pulse oximetry for oxygen saturation; single determination) in addition to an E/M service?
Yes, you can for the same reason that you may separately code anoscopy and an E/M service (see above). However, Medicare and almost all other payers will not pay separately for pulse oximetry done in conjunction with an E/M service on the grounds that recording pulse oximetry is no different than recording the patient’s temperature or other vital signs, which are not separately reportable.
Rehab ward
Our hospital has a rehabilitation ward that is considered an inpatient facility (i.e., not a “nursing home”). We often take care of patients on another ward for a few days and then transfer the patient to the rehab ward for two to three weeks of rehab. What E/M codes should we use on the day we transfer the patient to the rehab ward, the subsequent days he or she is there and the day the patient is discharged from the rehab ward?
Since the rehab ward of the hospital is not a nursing facility, it is just another part of the hospital to which the patient has already been admitted. Thus, you should use the subsequent hospital care codes (99231–99233) for the day of transfer to the rehab ward and all subsequent days except the date of discharge. Use the appropriate hospital discharge services code (99238 or 99239) for the date of discharge from the rehab ward, assuming that implies discharge from the hospital.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.