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Frequently Asked Questions


The Billing Compliance Office is happy to assist in researching answers to your frequently asked questions. Below are past Q&A  that were submitted to our office. At the bottom of the page are several links to valued resources pertaining to coding and billing questions.   Please feel free to submit any questions you would like to see answered to our offices or email to billingcompliance@ouhsc.edu.


Q:  We have a Medicare patient who presented to the ER with a post op infection during the global period of his surgical procedure.  Our physician was called to the ER to  see this patient and submitted charges for the I&D he performed in the ER.  I am not sure if we can report these services.  Is this I&D separately reportable or not?

A:
 
No, the service is not separately billable according to Medicare's definition of the global surgical package.  To bill for treatment of a complication during the global period, the service must be performed in the OR, ASC, endoscopy/laser suite, or ICU if the patient is critically ill and is unable to be transported to the OR.  The ER, holding area, PAR, non-certified procedure room does not constitute an approved location. 


Q:  If an inpatient in an acute care hospital is transferred to my services and it is the initial time for me to see the patient, can I bill an " Initial hospital care " code (99221 - 99223)?

A: No. According to the guidelines these codes are "used to report the first hospital inpatient encounter by the admitting physician".  For initial inpatient encounters by physicians other than the admitting physician, when a patient is referred to their service, one would use a subsequent hospital care code - 99231-99233.


Q: If I see a patient in my clinic and determine to directly admit this patient to the hospital, then turn this patient over to our departments "hospitalist", can I bill the clinic visit and the "hospitalist" bill the admit code?

A: No, not if you and the "hospitalist" are of the same group and same specialty only one provider can bill. You would bill a clinic visit or roll your visit into an admit to be bill by yourself or the "hospitalist."


Q:  If I see an established patient in my clinic and document a low level evaluation and management service (E/M 99213) but spend a total of 45 minutes with the patient discussing various aspects of his/her care, how can I bill for my services?

 

A:  You have two options.

•  First option is you could bill according to the counseling and coordination of care rules for E/M services if you document the total amount of time spent with the patient plus stating that more than 50% of the time was counseling and document an overview of what was discussed you can bill according to total time - 99215 = 40 minutes or more - Medicare 2004 fee = $111.15.

•  You could bill your level of service according to documentation, 99213 PLUS since you stated you spent a total of 45 minutes with the patient and CPT 99213 is approximately 15 minutes duration, you spent an additional 30 minutes with the patient. You would use an additional add-on code for prolonged time 99354 for the 30 minutes or more of documented prolonged time spent with the patient. Medicare reimbursement is 99213 = $48.53 + 99354 = $91.70 - total reimbursement = $140.23.


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Q:  What documentation is required for level of service for 99204, 99205 and 99244, 99245?

A:  Documentation for level of service for new patients and consultations is the same - all above listed codes are comprehensive level. The difference between level 4 and 5 of new patients or consultations is found within the decision making.

To bill a new patient or consultation all three areas of history, examination and decision making must meet or exceed minimum requirement as stated below:

History :

  • Four or more elements of history of present illness or 3 or more multiple chronic conditions (that you are addressing or affects your services)
  • Complete review of systems (ROS) which includes 10 systems or some pertinent systems with the statement "all others negative". The ROS is the main area lacking in physician documentation resulting in down-coding . A patient history form filled out by the patient or his/her representative or other qualified person, may be reviewed, signed and referred to by the billing provider for a complete review of systems.
  • At least one statement from each of the past medical, family, and social history areas.

 

Examination: According to the 1995 documentation guidelines (for specialty specific 1997 guidelines inquire at your Compliance Office)

  • Eight or more systems must be documented. The organ systems include; 1) constitutional, 2) eyes, 3) ears, nose, mouth, throat, 4)cardiovascular, 5) respiratory, 6) gastrointestinal 7) genitourinary, 8) musculoskeletal 9) skin, 10) Neurological 11) psychological 12) Hem/lymph/immo.

 

Decision Making:

  • Level 4 decision making is moderate complexity while level 5 is high complexity. A high complexity could present as a new problem to provider with additional workup planned along with review and/or ordering of lab, radiology and/or other tests in the medicine section of CPT along with reviewing of old records or discussing case with other health care providers. Additionally high complexity should include a patient with one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or cardiac electrophysiological tests, diagnostic endoscopies with identified risk factors, major surgery with risk factors, or drug therapy requiring intensive monitoring for toxicity. Level 5 should be reserved for your most complex patients that require complex management of multiple conditions or risk to life decisions or procedures.

 



Other Resources

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Healthcare Billing Compliance Office

Oklahoma City -
920 Stanton L. Young Blvd
Williams Pavilion, Ste 1230
Oklahoma City, OK 73104
Telephone: 405-271-1528
Fax: 405-271-2499

 

Tulsa -
4502 E 41st  ST, Ste 2G02
Tulsa, OK 74135
Telephone: 918-660-3627
Fax: 918-619-4058


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Last update 08/18/2014


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