- Can we bill for an E/M office visit and joint injection on the same day of service?
A: Yes, if the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. To report this situation you would append modifier 25 to the E/M service for that day. Tip: Documentation should be separated from the documentation of the procedure.
- What constitutes a new vs. an established patient in our practice?
A: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. 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.
- I’ve always heard that if I spend more than 50% of my time with a patient face-to-face, counseling or in coordination of care that I can use time as a basis to code. What do I need to document in the chart to satisfy the auditors?
A: You should note the total amount of time that was spent with the patient along with something like, “I spent___minutes with the patient, over half the time spent was discussing her diagnosis and treatment.” It would also be advantageous to describe in greater detail what was discussed, i.e. test results, medication options, possible side effects, and lifestyle changes. Rheumatic patients with chronic conditions might come in office for follow-up care and the physician knows the history already so a lot of time is spent in counseling and coordination of care, so time might be the most logical choice in determining the level of E&M. Remember, document total time spent and make sure you indicate that over 50% of the time was spent in counseling and/or coordination of care.
- When documenting time, where in the record do you place this information?
A: There are no requirements as to where in the medical record time should be recorded for the office visit. The documentation requirements only indicate that the medical record should indicate face-to-face time for office visits as total time spent in the E/M encounter, amount of time spent in counseling the patient and items covered in the discussion.
- Does every encounter have to state the chief complaint in the medical record?
A: Yes. If there is no chief complaint listed a carrier can state; because there was no documentation as to why the patient is in the office there is no medical necessity for the visit.
- Can a chief complaint be listed simply as follow up?
A: No there has to be a explanation as to what the follow up is for.
- Does analysis of data (EKG, CXR, DEXA) reduce the intensity of physical examination needed to qualify for the higher code for the established patient follow up office visit?
A: As an established patient visit requires only two out of three components for a level of service qualification, the lower physical exam would not drop the level of service if the medical decision making and history were higher level.
- If a patient with an established problem presents to a new provider, is diagnosis of the problem a “new problem”?
A: Problem status is relative to provider and not relative to the patient; therefore the problem would be new.
- Can you bill the patient for cancellations?
A: Yes the physician can charge for this as long as all patients are subject to the cancellation fee. Also the notice should be displayed prominently in the office where patients can see it.
- Can you bill 99211 for the time spent by your staff obtaining a prior authorization of any kind for the patient?
A: The answer is no. An Evaluation and Management service must be given. This means, the patient’s history should be reviewed, a limited or some level of medical decision making should be made. If there is not a clinical need shown; then the 99211 should not billed.
- Can you bill an E/M service with an infliximab infusion?
A: Yes, you can if there is "a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed." Even if the E/M service was prompted by the symptom or conditions for the procedure or service; a different diagnosis is not required for visit on the same date.
- Is it permissible to bill for the education and training for a patient’s self management of a disease?
A: Yes, a qualified, nonphysician health care professional can provide training for a patient’s training for the self management of their disease.
- 98960 Education and training for patient self-management by a qualified, nonphysician professional health care professional using standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient.
- 98961 2-4 patients
- 98962 5-8 patients
