CODING & DOCUMENTATION

According to CPT, “A patient is considered an outpatient until inpatient admission to a health care facility occurs.” Given that the patients are outpatients from a coding perspective, the question then becomes whether this is a consultation service. If you are called in as a consultant and the service meets the CPT definition of a consultation, you may submit the office or other outpatient consultation codes (99241–99245). CPT states that these codes are used to report “consultations provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital observation services….” The CPT guidelines related to initial observation care also recommend using codes 99241–99245 for observation encounters by physicians other than the supervising physician. If you do not believe that the services meet the definition of a consultation, you should consider using the appropriate office or other outpatient services codes (99201–99215). For example, if a surgeon calls you in to “evaluate and manage” pre-existing medical conditions (e.g., hypertension and diabetes) for which you have previously seen the patient, an established patient office or other outpatient services code (99211–99215) would be more appropriate than a consultation code.

If the service provided is primarily medical in nature and does not include psychotherapy or other psychiatric services, you should submit the appropriate CPT code for office or out-patient E/M services (99201–99215). However, if the service involves psychotherapy or other psychiatric services, you should submit an appropriate code from the psychiatry section of CPT (90801-90899).In either case, the appropriate diagnosis code will depend on the nature of the patient’s depression. For example, the diagnosis code for a single episode of acute depression is 296.2X, for a recurrent episode is 296.3X, for neurotic depression is 300.4 and for postpartum depression is 648.4X. (A fifth digit is required when an “X” appears; a list of fifth digits can be found in the ICD-9 manual.) The code for depression not elsewhere classified or otherwise specified is 311.

No. Medicare has not established any similar codes for nursing-facility patients.

From a CPT perspective, collection of the specimen by venipuncture or finger/heel/ear stick is not considered an integral part of the laboratory procedure performed and, thus, may be coded separately. The CPT code for routine venipuncture is 36415, and the CPT code for finger/heel/ear stick is 36416. Note that Medicare uses G0001, not 36415, for routine venipuncture and does not allow separate payment of 36416. The laboratory CPT codes (80000–89399) should be used to report the performance of the lab test only.

With the full implementation of the practice-expense component of the Medicare Fee Schedule, all supplies, such as surgical trays, are now included, or “bundled,” in the payment for the procedure, so Medicare won’t reimburse you for this code. Some non-Medicare payers may still use it, and others may alternatively allow CPT code 99070, “Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided),” instead.

You should submit CPT code 89321, “Semen analysis, presence and/or motility of sperm.”

No, it would not be appropriate to report 99080 in conjunction with 99455 or 99456. The descriptors for 99455 and 99456 explicitly state that these codes include “completion of necessary documentation/certificates and reports.”

There are multiple ways to code counseling with patients, depending on the nature of the counseling:If the counseling is problem-oriented and takes up more than half of your face-to-face time with the patient, you may code the service on the basis of the total time spent with the patient by using a problem-oriented evaluation and management (E/M) code. For example, if you spend 15 minutes of a 25-minute office visit counseling an established patient about the impotence you’ve been treating him for, you can submit 99214 for that service. [See “Time Is of the Essence: Coding on the Basis of Time for Physician Services,” FPM, June 2003, page 27, for more on this topic.]If the counseling is preventive in nature, you may consider submitting one of the preventive medicine individual counseling codes (99401–99404) based on the approximate amount of time spent with the patient.If the counseling rises to the level of psychotherapy, you may want to consider submitting one of the psychotherapy codes (90804–90857). CPT defines psychotherapy as “the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.”

No. CPT code 99211 describes an “office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician.” If a patient simply drops off a urine sample without consulting with a nurse or another clinical staff person, such that there is no “evaluation and management” of the patient, you should not submit 99211. When 99211 is used, the presumption is that the patient saw the nurse or another clinical staff person face-to-face and that the documentation in the patient’s chart substantiates that and the medical necessity of the encounter.