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CINDY HUGHES, CPC

Fam Pract Manag. 2006;13(5):32

Cindy Hughes is the coding and compliance specialist for the AAFP and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.

Coding an injection with an office visit

In the past, I have always billed 99213 with CPT injection code 90782 and HCPCS injection codes J1100 and J1030. Recently, the insurance company has denied the office visit as invalid with CPT code 90782. What are we doing wrong?
First, 90782 is not valid in 2006; instead use 90772, “Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.” Second, you must attach modifier −25 to your office visit code when billing an injection code on the same date to indicate that you performed a significant, separately identifiable service. Failure to include modifier −25 may mean that you will only get paid for the injection. Note also that Medicare and many private payers will not allow payment for a 99211 visit and an injection on the same date, even with modifier −25. You should continue to bill for the injectable medication as before.

E/M services for unrelated problems on the same day

Can two physicians in the same group and same specialty bill for an evaluation and management (E/M) service on same day if they are seeing a patient for unrelated problems?
Yes. Chapter 12, section 30.6.7B of the Medicare Claims Processing Manual says that “... carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter” (emphasis added). Most private payers have the same policy.

ED services and admission on the same day

If a patient is seen by an emergency department (ED) physician and is admitted by another physician in the same practice on the same day, can both physicians bill an E/M service?
Yes. The ED physician may bill for the ED services, and the admitting physician may bill the initial hospital care service. However, if both physicians are of the same specialty as well as the same practice, the payer may bundle the ED services into the initial inpatient care services.

Debridement services

Is it correct to bill debridement codes in conjunction with an E/M service?
An E/M service that consists of the normal pre-service work for a debridement should not be separately billed. If a significant, separately identifiable E/M service is provided on the same date, the E/M service can be billed with modifier −25, although it might not be paid. Some Medicare carriers have taken the stance that only an E/M service unrelated to the debridement is separately billable. Check with your Medicare carrier for guidance.

Mini-mental status exams

Can a mini-mental status exam be billed in addition to a regular office visit?
No. The mini-mental status exam is considered part of the reimbursement for the E/M service.

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.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

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