CODING & DOCUMENTATION

The CPT definition of face-to-face time is defined as “only that time that the physician spends face-to-face with the patient and/or family.” Note that inpatient encounters are different because CPT defines unit/floor time as both time spent at the patient bedside and on the unit/floor rendering services for that patient.

Unless your practice provides a medically necessary evaluation and management (E/M) service in addition to the medication refill, you should not use code 99211. Refills alone are not separately reportable services. A level-I nursing visit requires evaluation and management of a patient except when it is billed for an injection provided without direct physician supervision.

Yes. CPT and Medicare state that you may bill for an E/M service on the same date as a well check-up (preventive service). Although some payers bundle these services, many do not. For more information on billing preventive services and E/M services on the same date, see “Same-Day E/M Services: What to Do When a Health Plan Won’t Pay,” FPM, April 2006, and “Making Sense of Preventive Medicine Coding,” FPM, April 2004.

When a physician discontinues a procedure at his or her discretion and not because of patient instability, it should be reported with modifier -52 attached to show that the procedure was significantly reduced. In this case, you would submit 58100–52 for a discontinued endometrial sampling with or without endocervical sampling and without cervical dilation. The payer will need information on the extent of the procedure that was performed. This information can be submitted in a claim narrative or as a report attached to a paper claim.

Pediatric and neonatal critical care services should be reported by a single physician or single physician group only once per patient per day, regardless of the number of encounters in a given setting. When another physician from a different group provides critical care services on the same day, he or she should report the time-based critical care services (99291–99292) instead. If you or another physician in your group will not be caring for the critically ill patient at the receiving hospital, then either you or the physician at the receiving hospital must bill 99291 or 99292 while the other bills 99293 or 99295. In addition, if you attend the critically ill or critically injured pediatric patient during transport and provide direct face-to-face care, report 99289 for the first 30 to 74 minutes and 99290 for each additional 30 minutes.

Code 99058 should be reported when you provide services on an emergency basis in the office that disrupt other scheduled office services. You do not need to be called out of a room to bill 99058, but your scheduled appointments must be disrupted to care for a patient who requires immediate care.Note also that the diagnosis and chief complaint of the encounter should indicate the emergent nature of the visit. Link 99058 to the diagnosis code that best identifies the reason for the emergency. For instance, say the dentist down the hall phones and asks you to see one of his patients right away for chest pain. You see the patient ahead of other scheduled patients only to determine that he has indigestion. A claim with 99058 linked to a diagnosis code for indigestion is not indicative of an emergency; however, a claim with a primary diagnosis of indigestion and a second diagnosis of chest pain linked to code 99058 is indicative of an emergency.Be sure to watch payer policies on this code. Medicare and Medicaid typically bundle this code with other services provided, and private payers may limit payment as well.

Use the appropriate code from 97802–97804. These codes should be reported only for services provided by nutritionists. If a physician provides medical nutrition therapy, the E/M or preventive services codes should be used. Private payers may also accept HCPCS codes S9452, S9465 or S9470 for a session of nutrition therapy provided by a nutritionist.You might also consider offering medical nutrition therapy or diabetes self-management training services for Medicare patients. Medical nutrition therapy may be billed separately as a stand-alone benefit, and dieticians and nutritionists who apply for Medicare provider status can bill for services under both medical nutrition therapy and diabetes self-management training. For these services, you can use a CPT code from the 97802–97804 series, and when additional medical nutrition therapy is ordered in the same year, you can use G0270 and G0271. See Chapter 15, Section 300 of the Medicare Benefit Policy Manual at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf for specifics on diabetes self-management training.

Yes, you would charge for both the DTP and the immunization administration. However, because the DTP is not a covered service under Medicare, it is not necessary to submit a claim to Medicare for these services unless the patient requests it (for example, for the purpose of enabling a subsequent submission of the claim to a secondary insurer). If you do submit a claim to Medicare, include the -GY modifier on your codes to indicate the services are statutorily excluded from Medicare coverage. It is a good idea to provide the patient with a Notice of Exclusion from Medicare Benefits (NEMB), which is intended to ensure the patient understands that the service is not a covered benefit under Medicare Part B. This form is available in English and Spanish at http://www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp.

CPT specifically addresses this in the E/M services guidelines section in the front of the CPT manual, under the heading “New and Established Patient”: “In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.”