Beware of the tendency to code the visit based on the complexity of the diagnosis, rather than the extent of decision making involved. A new patient visit from a woman, age 57, who presents with congestion and a persistent cough occasionally accompanied by chest pain might warrant a 99204 if her medical history (eg, obesity, hypertension, and gastroesophageal reflux disease) and review of systems made it necessary to rule out acute myocardial infarction and congestive heart failure, among other serious conditions, before arriving at a diagnosis of bronchitis. If you’re unsure of whether you can use the higher code, review the coding and documentation requirements in TABLE 2.
3. Remember to use modifier -25 with the proper documentation
The Office of Inspector General notes that you can bill for an office procedure performed on the same day as you evaluate the patient, if the procedure “is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure….” To do so, though, it is necessary to attach modifier-25 to the evaluation and management (E/M) code, and to provide evidence that you performed 2 separate services.
Proper documentation is critical here. In 2002, Medicare approved some 29 million claims using modifier -25, then disallowed nearly 35% of them for failing to meet the documentation requirements.6 How can you avoid a similar fate?
While most third-party payers do not require physicians who bill for an E/M service and a procedural service for the same patient on the same day to submit 2 separate progress notes, the work performed for each must be clearly defined. If you saw a patient with diabetes for a medication check and she asked you to remove a wart, you would need to document the dimensions, depth, and location of the wart, along with details of your targeted evaluation and management.
4. Know when to bill for preventive and E/M services
We’re all familiar with the patient who comes in for a yearly health maintenance examination, then wants to discuss her depression or chronic back pain. In such a case, you may be justified in billing for both preventive services and an office visit—again, using modifier -25 to indicate that you provided significant, separate services.
The distinction can be harder to establish than when separating an E/M service and a procedure, however. If the acute or chronic problem that you evaluate is stable and closely related to the preventive examination—well-controlled asthma not requiring a change in medication, for example—submitting an E/M code is not warranted. But a new problem or an exacerbation of an existing problem requiring a significant history, physical examination, and treatment beyond what would typically be performed during a routine preventive visit would be a valid reason to bill for E/M services.
Management of 2 or more medically significant chronic problems requiring prescription refills and either laboratory or radiographic tests also justifies concomitant billing of an E/M code.
The best laid plans…. Even when billing for preventive and problem-oriented care is appropriate and the proper codes and documentation are submitted, you may not be reimbursed for both. Some third-party payers will pay a portion of each; others will deny the additional claim entirely. There are also some health plans that will require any patient who generates 2 charges on the same day to pay 2 separate copays.
5. Charge for patient counseling
When more than half the time you spend with a patient is devoted to counseling or coordination of care, “time may be considered the key or controlling factor to qualify for a particular level of E/M service,” according to CPT guidelines.4 That is, you may be able to justify the use of a higher level E/M code based solely on time, regardless of the complexity and detail of the medical history, physical examination, or medical decision making (TABLES 1 AND 2).
Medicare’s Documentation Guidelines for E/M Services direct physicians to document the total time of the patient encounter and to describe in detail the nature of the counseling or activities to coordinate care.7 That said, time spent before and after the face-to-face encounter—retrieving and reviewing records or test results in preparation for the visit and arranging referrals or communicating with other health care providers afterwards, for example—cannot be counted toward the total time of the patient encounter.