CODING & DOCUMENTATION

Code 99080 is intended to be used when a physician fills out something other than a standard reporting form, such as paperwork related to the Family and Medical Leave Act. This code does not apply to the completion of routine forms, such as hospital-discharge summaries. Also note that it would not be appropriate to submit 99080 in conjunction with 99455 or 99456, which are the codes for work-related or medical disability evaluation services. The descriptors for these codes explicitly state that they include “completion of necessary documentation/certificates and reports.”

When multiple procedures are done at the same visit, you should report the primary procedure as listed in CPT. This is typically considered to be the procedure with the most relative value units (RVUs) in the Medicare fee schedule. Additional procedures may be identified by attaching modifier -51, “Multiple procedures,” to the corresponding CPT code(s), unless the CPT manual indicates that the code(s) is modifier -51 exempt or is an add-on code. If a significant, separately identifiable E/M service is done at the same encounter, you may submit a code for it as well. If the procedures are minor (e.g., benign skin lesion excision), attach modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” to the E/M code. If the procedures are major (e.g., fracture care), consider attaching modifier -57, “Decision for surgery,” to the E/M code. In either case, your documentation should clearly establish the separate nature of the E/M service, and you may even want to write a separate note for the E/M service.

You should use CPT code 36415,“Collection of venous blood by venipuncture.” Prior to this year, Medicare had its own HCPCS code, G0001, “Routine venipuncture for collection of specimen(s),” for this service.

If the orthopedic surgeon was requesting your opinion on the patient’s fitness for surgery and you shared your opinion or advice with the orthopedic surgeon in writing, you may submit the appropriate consultation code (99241–99245). Otherwise, you should submit an appropriate office or outpatient visit code based on the history, exam and medical decision making involved, as you suggested, assuming the service was done in your office or another outpatient setting. Note that some payers may not consider this service medically necessary. If you suspect this may be the case, you may want to warn the patient that this service may not be covered and even consider having the patient sign a payment responsibility waiver prior to providing the service.

You should submit 20552 “Injection(s); single or multiple trigger point(s), one or two muscle(s),” or 20553, “... three or more muscles.” The code is based on the number of muscles injected, not the number of injections given. Note that you should only submit 20552 or 20553 once per session since either code covers multiple injections. Also note that you should clearly document the location of injections, number of injections and number of muscles involved. If you also perform a significant, separately identifiable E/M service at the same visit, you should attach modifier -25 to the appropriate E/M code.

When you provide the interpretation and written report (i.e., the professional component) for a diagnostic test, you should submit the code for the test and attach modifier -26, “Professional component,” or submit the appropriate CPT code for the professional component of the test. For example, if you interpreted and provided a written report on a single-view chest X-ray taken outside your office, you would submit 71010, “Radiologic examination, chest; single view, frontal,” with modifier -26 attached. This indicates that you provided the professional component of the X-ray while someone else provided the technical component. If you interpreted and provided a written report on a routine ECG, you would submit the CPT code for that service, 93010, “Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.”Note that if you are simply reviewing test results that have already been interpreted or reinterpreting the technical component of a test that has already been interpreted by someone else, you are not providing a separately reportable service. Such a review is considered part of the E/M service.

Assuming that all of the services you performed otherwise met CPT’s definition of critical care services, you should submit the pediatric critical-care patient transport codes 99289 and 99290 for the face-to-face time you spent with the patient. This time should begin when you assumed primary responsibility of the patient at the referring hospital and end when the receiving hospital accepted responsibility for the patient’s care. Code 99289 is for the first 30–74 minutes, and code 99290 is for each additional 30 minutes. Since you spent a total of four face-to-face hours with the patient, you should submit 99289 once and 99290 six times. (Note that if the patient were older than 24 months, you would code the time spent providing critical care services to the patient with 99291 for the first 30–74 minutes and 99292 for each additional 30 minutes.) Then, for any services you provided after the patient was admitted to the receiving hospital, you should submit the appropriate inpatient pediatric critical care code (99293 or 99294).

If you review the X-ray and provide and document your own interpretation of it in a written or dictated report as appropriate for a radiologic interpretation, you have fulfilled the intent of the documentation guideline you quoted and would qualify for the two points assigned to such an independent interpretation in standard E/M coding tools. However, if you only order the X-ray and/or review the interpretation provided by the radiologist, you would only qualify for one point toward scoring the “amount and complexity of data to be reviewed.”