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 firstname.lastname@example.org.
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.
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)?
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.
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?
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."
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?
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.
What documentation is required for level of service for
99204, 99205 and 99244, 99245?
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.
bill a new patient or consultation all three areas of history, examination
and decision making must meet or exceed minimum requirement as stated
- Four or more
elements of history of present illness or 3 or more multiple chronic
conditions (that you are addressing or affects your services)
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.
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.
- 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