Coding & Documentation - February 2007 - Family = Practice Management

February 2007, Vol. 14, No. 2, pages 23-4

Coding & Documentation

Cindy Hughes, CPC

Documenting modifier -25 services

Q Do I need to write a separate note when I = use=20 modifier -25 at a preventive visit?

A CPT does not require that you separately = document=20 preventive and problem-oriented services, but it is in your best = interest to do=20 so. The CPT descriptor for modifier -25 states: "A significant, = separately=20 identifiable evaluation and management (E/M) service is defined or = substantiated=20 by documentation that satisfies the relevant criteria for the respective = E/M=20 service to be reported."

Payers often request records before paying = for both=20 services. When there are two separate entries for the services, the work = involved for each is more easily defined and the payer is less likely to = deny=20 the claim on the basis that the work associated with the = problem-oriented=20 service is not distinct from that of the preventive medicine = service.

Coding for venipuncture

Q If a patient presents to my office for = fasting blood=20 work only, with no E/M service needed, can we charge a 99211 if our = nurse=20 performed the blood draw?

A No. You should report the code that most = accurately=20 describes the service, and in this situation, that's 36415, "Collection = of=20 venous blood by venipuncture," because a venipuncture is the only = service=20 provided. This should not be confused with an injection given without = direct=20 physician supervision, which can be = reported with=20 99211, according to CPT. Note that because Medicare's incident-to = billing=20 guidelines require direct physician supervision of services billed with = 99211,=20 you cannot bill Medicare (or any other payer that follows Medicare's = incident-to=20 guidelines) for an injection given without direct physician supervision = unless=20 it was provided by a midlevel provider and reported under his or her own = provider number.

Medication refills

Q I often see patients for a follow-up of = chronic=20 medical problems after I authorize a single refill of their medications = over the=20 phone - just enough so that they do not run out before the visit. I = review=20 patients' medication lists prior to authorizing these refills. Can this = work=20 influence the level of service of the subsequent office visit, or do I = have to=20 repeat the review?

A E/M services are valued to include certain = pre-service=20 and post-service work. The Centers for Medicare & Medicaid Services = has=20 defined pre-service work as preparing to see a patient, reviewing = records and=20 communicating with other professionals when appropriate. Post-service = work=20 includes coordination of care, documentation and telephone calls with = the=20 patient, family members or other health professionals associated with = the=20 delivery of care to the patient (excluding separately billable services, = such as=20 care plan oversight).

A medication refill is generally part of the=20 post-service work, regardless of the amount of time lapsed. However, = reviewing=20 the patient's medications counts as evaluating the patient's past = history.=20 According to Medicare's Documentation Guidelines = for=20 Evaluation and Management Services, one of the requirements of a = detailed=20 history is that the pertinent past, family or social history be = reviewed. If the=20 chart note that was produced at the time of the refill indicates that = you=20 reviewed the patient's medications, you can simply document the date of = that=20 prior note, e.g., "Medication list reviewed on 2/1/07 with refill = request."

Also, your decision to continue current medications = based on the=20 results of this encounter should be documented and included when you = calculate=20 the medical decision making. Prescription drug management is associated = with a=20 moderate level of risk, which may influence the level of medical = decision=20 making.

Coding for services in a residency program

Q I am a teaching physician in a family = medicine=20 residency program. What is the correct way to use the -GC and -GE = modifiers?

A When you are supervising only one resident = and you are=20 present during the key portion of a service and immediately available = during=20 other parts of the service, use modifier -GC in item 24d of the CMS-1500 = form to=20 indicate the service was performed in part by a resident under the = direction of=20 a teaching physician.

When the primary care exception applies, use = modifier=20 -GE. The primary care exception says the teaching physician does not = need to be=20 present in certain situations when the resident provides a level-I, -II = or -III=20 service. To be eligible for the exception, the following conditions must = be=20 met:

=E2=80=A2 The resident must have completed at least six = months of an=20 approved graduate medical education residency program.

=E2=80=A2 The teaching physician may not supervise more = than four=20 residents at any given time.

=E2=80=A2 The teaching physician must be in a proximity = as to constitute=20 immediate availability.

=E2=80=A2 The teaching physician must review the care by = the resident=20 during or immediately following the service.

=E2=80=A2 The teaching physician must document the = extent of his or her=20 review and direction in the care of the patient.

Your program must attest in writing that these = conditions were=20 met, and you must maintain records demonstrating that you qualify for = the=20 exception. When billing for this exception, use modifier -GE in item 24d = of the=20 CMS-1500 form to indicate the service was performed by a resident = without the=20 presence of a teaching physician under the primary care exception.

For the complete list of rules for supervising = physicians in=20 teaching settings, see chapter 12, section 100 of the Medicare Claims Processing Manual at http://ww= w.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Hospital discharge

Q I saw a patient in the morning as part of = my regular=20 hospital rounds. The patient was discharged that afternoon. How should = the visit=20 in the morning and the discharge in the afternoon be coded?

A You should use a hospital discharge code to = report all=20 services provided to the patient on the date of the discharge, assuming = it is=20 not the same date as the admission. Report hospital discharge code 99238 = if you=20 spent a total of 30 minutes or less on the discharge, or report 99239 = for more=20 than 30 minutes. This is true even if the time you spent on the = discharge=20 services is not continuous. You should include the time of the morning = visit in=20 the time spent performing the discharge activities later that day = including, as=20 appropriate, the final examination, discussion of stay, instructions for = continuing care to all caregivers, as well as the preparation of = discharge=20 records, prescriptions and referral forms. Because these are time-based = codes,=20 be sure to document how much time you spent rendering the services.

Documentation shortcuts

Q When documenting subsequent hospital care, = is it=20 acceptable to state in the assessment, "See assessment of prior date," = if there=20 is no change in the diagnosis or problems list?

A While referencing a prior note is acceptable, = a more=20 direct statement may better support your level of service, such as "No=20 significant changes since the note of the prior date." Not only will = this=20 provide more thorough documentation, it could also help you defend = yourself in=20 case of a lawsuit.

Coding for diphenhydramine hydrochloride

Q What is the proper code for 50 mg of = Benadryl?

Do you have a coding or documentation = question?

Send it to FPM = by e-mail,=20 fpmedit@aafp.org; by fax,=20 913-906-6000; or by mail, Family Practice = Management,=20 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. Include = your=20 address, daytime phone number and fax number. We cannot respond to all = questions=20 we receive, but we will publish answers to selected questions.

A Benadryl is a brand name for diphenhydramine=20 hydrochloride. Use HCPCS code J1200 for up to 50 mg of Benadryl given=20 intravenously or intramuscularly, or Q0163 for a 50 mg dose of Benadryl = given=20 orally as an anti-emetic. (See chapter 17, section 80.2 of the Medicare Claims Processing Manual at http://ww= w.cms.hhs.gov/manuals/downloads/clm104c17.pdf=20 forspecial rules that apply under Medicare.) You can reference the HCPCS = codes=20 for drugs online at http://www.cms.hhs.gov/hcpcsreleasecodesets/downloads/drug2006.pdf= .

Multiple nebulizer treatments

Q What code should I report for providing two = nebulizer=20 treatments to an asthma patient in the same day?

A Report code 94640 two times, and add modifier = -76 to=20 the second code to indicate that you repeated the procedure on the same=20 date.

Editor's note: While this = department=20 attempts to provide accurate information and useful advice, third-party = payers=20 may not accept the coding and documentation recommended. You should = refer to the=20 current CPT and ICD-9 manuals and the Documentation=20 Guidelines for Evaluation and Management Services for the most = detailed=20 and up-to-date information.

About the Author

Cindy Hughes is the AAFP's coding and compliance = specialist=20 and is a Family Practice Management contributing editor. Author = disclosure:=20 nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel, = which=20 includes Robert H. Bosl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. = Felger,=20 MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance = Department=20 of Physicians Clinic; Emily Hill, PA-C; Kent Moore; Joy Newby, LPN, CPC; = P. Lynn=20 Sallings, CPC; and Susan Welsh, CPC, MHA.

Copyright =C2=A9 2007 by the American = Academy of Family=20 Physicians.
This content is owned by the AAFP. A person viewing it = online=20 may make one printout of the material and may use that printout only for = his or=20 her personal, non-commercial reference. This material may not otherwise = be=20 downloaded, copied, printed, stored, transmitted or reproduced in any = medium,=20 whether now known or later invented, except as authorized in writing by = the=20 AAFP. Contact fpmserv@aafp.org = for=20 copyright questions and/or permission=20 requests.