Coding: Ask Janet
Do you have a coding question for Janet Smith, TNAAP's Coding Educator?
Email your questions to: askjanettnaap@aol.com
If you would like to contact Janet Smith, you may also email her: janettnaap@comcast.net
Frequently Asked Coding/EPSDT Questions
(NEW!) Q. When a patient leaves the office after diagnosis and treatment of chief complaint in the morning and the parent wants to bring the child back in the afternoon for a totally different complaint, is the second encounter billable? The child saw two different physicians on the same day, at the same clinic?
A. Two evaluation and management services cannot be billed on the same day by two different physicians if they are in the same practice/same specialty. What you can do is combine the visits together and report a higher level of E/M service based on the documentation by both physicians taking into consideration the number of problems managed and treatment rendered, but only one physician may report the combined encounters.
Q. Can a teaching physician bill for a preventive medicine visit provided by a resident under the primary care exception rule?
A. No. The primary care exception rule limits the teaching physician's billing to 99201-99203 for new patients and 99211-99213 for established patients. Preventive medicine codes are not included in the exception at this time. The American Academy of Pediatrics is currently advocating for their inclusion.
Q. Which CPT codes are used to report services provided after hours or on weekends? (May 2007)
A. If the service is provided at times other than regularly posted office hours, or days when the office is normally closed, report 99050 in addition to the basic service. If the service is provided during regularly scheduled evening, weekend, or holiday office hours, report 99051 in addition to the basic service. Many payors recognize the expense involved with the overwhelming increase of patients being seen in urgent care or emergency room settings and reimburse providers separately for the after hours add-on codes.
Q. When are the new ICD-9 and CPT codes effective for 2007?
A. ICD-9 2007 codes become effective on October 1, 2006. CPT 2007 codes are effective beginning January 1, 2007.
Q. If a newborn is sick on the initial day hospital visit and then is well on subsequent day visits and at discharge, which CPT codes would be reported?
A. Report the initial hospital care codes on the first day, 99221-99223. If the newborn is well with no problems on subsequent days, report 99433 (subsequent normal newborn codes), and then report 99238-99239 on the discharge day.
Q. Which CPT codes should be reported for the administration of vaccines if one is given orally and one is given subcutaneous?
A. 90471 and 90474. 90471 would be reported as the base code for the subcutaneous administration of a vaccine. 90474 would be reported for the additional vaccine that is administered orally.
If physician counseling is provided with the vaccine administration in children less than 8 years of age, 90465 would be reported as the base code for the administration of the initial subcutaneous vaccine and 90468 would be reported for the administration of the additional oral vaccine.
Q. Which CPT codes are reported for a preventive visit and developmental screening for a 5-year old established patient?
A. 99393-25 and 96110. The preventive visit requires the modifier 25 to indicate that on the day a procedure or service identified by a CPT code was performed, a significant, separately identifiable evaluation and management service was performed.
Q. Is it appropriate to report 99211 in addition to the vaccine administration code when a child presents for vaccine administration only?
A. No. In order to report 99211 in addition to the vaccine administration, the nurse must perform a service that is significant, separate, and medically necessary.
An example would be if the child returned to the office to receive a vaccine that was not administered at a well visit because of an illness or other problem. The nurse would perform an evaluation and management service to ensure that the child was well and then administer the vaccine. In this case, 99211-25 with would be reported in addition to the vaccine administration code. The ICD-9 code reported for 99211 would be V67.59 for a follow-up examination and then the appropriate CPT and ICD-9 codes would be reported for the vaccine administration.
Q. Is a pre-op evaluation by a PCP considered a consult?
A. If all the CPT requirements are met (request was made by a physician for the service, the service was rendered, a report was sent back with the findings and recommendations) then by CPT guidelines, it is a consultation. A PCP should not be exempt from reporting a consultation code, but many carriers feel that PCPs should not report a consultation. It is really up to the individual carrier to determine this. In this scenario, practices should contact the carrier to determine if they allow for pre-op exams to be coded as a consultation. Otherwise the service should be reported with 99212-99215 (established patient).
Q. If a baby is seen by a NICU physician while in the hospital and then sent to the private pediatrician for circumcision. Can the pediatrician bill a consult and the circumcision or just the circumcision since the NICU doctor is not asking for advice or opinion? Or could you bill a new patient visit and circumcision?
A. If the private pediatrician performs an E/M service prior to performing the circumcision and the baby meets the CPT definition of a "new patient" then the pediatrician would code the new patient office visit (not consultation) and the circumcision code. Please note if they are done on the same day the 25 modifier would need to be attached to the E/M service.
Do you have a coding question for Janet Smith, TNAAP's Coding Educator?
Email your questions to: askjanettnaap@aol.com
