Coding Conundrums
Presented by Lori Dafoe, CPC
& Marisa Clauson, CPC
Family VisitsCPT Assistant Archives - Evaluation
and Management (Q&A) (March 2013),
page 13

Assuming the physician wants to report
the E/M service based on time with nonface-to-face patient contact, is it
appropriate to report an office visit code
(99211-99215) when the patient is not
present? For example, the family of a
stroke patient comes in to discuss the
patient's care with the physician, while the
patient is left at home.
Family Visits


Yes. The evaluation and management (E/M) services guidelines on
page 8 of the 2013 CPT Professional Edition codebook state, "Faceto-face time (office and other outpatient visits and office
consultations): For coding purposes, face-to-face time for these
services is defined as only that time spent face-to-face with the
patient and/or family. This includes the time spent performing such
tasks as obtaining a history, performing an examination, and
counseling the patient."
When counseling and/or coordination of care dominates (ie, more
than 50%) the encounter with the patient and/or the patient's
family (face-to-face time in the office or other outpatient setting or
floor/unit time in the hospital or nursing facility), then time shall be
considered the key or controlling factor to qualify for a particular
level of E/M service. This includes time spent with parties, who have
assumed responsibility for the care of the patient or decision
making regardless if they are family members (eg, foster parents,
person acting in loco parentis, legal guardian). The extent of
counseling and/or coordination of care and the time spent
performing this function must be documented in the patient's
medical record. Although this reporting method reflects the intent
of CPT coding, third-party payers may request that these
services be reported differently.
Allergy Injection

Physician is out of the office. Patient
presents for an allergy injection.

Can the nurse give it/bill for it (CPT
95115-95117)?
Allergy Injection
The nurse can technically give the
injection in conjunction with state
guidelines. Malpractice carriers would
recommend that the physician be present.
 “Incident To” guidelines mandate that a
supervising provider be present in order
to bill for a service that requires
supervision.

Nurse Phone Call
Patient calls in for protime results. The
nurse reviews all information including
review of systems over the phone and
gives instructions on adjusting meds and
further testing. At least 10 minutes is
spent on the call.
 Can you bill a nurse visit (CPT 99211) for
the phone call?

Nurse Phone Call


NO, 99211 would not be appropriate.
Medicare requires that all E&M services be
“face-to-face”.
Other carriers, may allow payment.
99441-99443 Telephone evaluation and
management service provided by a physician
to an established patient, parent, or guardian
not originating from a related E/M service
provided within the previous 7 days nor
leading to an E/M service or procedure
within the next 24 hours or soonest
available appointment
CPT Assistant Archives - Evaluation and
Management (Q&A) (March 2013)

If an OB/GYN physician was unable to
perform a pelvic examination and pap
smear during a preventive medicine
evaluation and management (E/M) service
and performed the pelvic examination
and pap smear on a date subsequent to
the preventive medicine E/M service visit,
would it be appropriate to separately
report for the subsequent visit?
Pap & Pelvic: AMA Comment, CPT Assistant
Archives - Evaluation and Management
Services (August 2004), page 10c

NO. The appropriate preventive medicine
E/M service code should be reported for
the first visit. As a pelvic examination and
pap smear are considered part of a
comprehensive OB/GYN preventive
medicine E/M service, no additional
reporting is necessary for the pelvic
examination and pap smear performed on
the subsequent date.
Breast & Pelvic Exam

Whenever the provider documents a that
the breast and pelvic areas were
examined, coders should automatically
assign HCPC G0101.
G-Code for Breast & Pelvic Exam

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

FALSE. According to a Centers for Medicare & Medicaid Services (CMS) Medicare
Learning Network product, G0101 is payable under the physician fee schedule
when at least seven of the following 11 elements are included in the
exam:
Inspection and palpation of breasts for masses or lumps, tenderness, symmetry,
or nipple discharge
Digital rectal examination including sphincter tone, presence of hemorrhoids, and
rectal masses
External genitalia (for example, general appearance, hair distribution, or lesions)
Urethral meatus (for example, size, location, lesions, or prolapse);
Urethra (for example, masses, tenderness, or scarring)
Bladder (for example, fullness, masses, or tenderness)
Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic
support, cystocele, or rectocele)
Cervix (for example, general appearance, lesions or discharge)
Uterus (for example, size, contour, position, mobility, tenderness, consistency,
descent, or support)
Adnexa/parametria (for example, masses, tenderness, organomegaly, or
nodularity)
Anus and perineum
In reviewing this issue, the ACOG Health Economics and Coding Committee
determined that G0101 should be covered if the documentation notes the absence
of the breast(s), cervix, uterus, fallopian tube(s), and/or ovary(s).
CPT Assistant Archives - Reporting of
Cutaneous Excision Pending Pathology
(May 2012)

If the provider is unsure whether the
lesion is benign or malignant, coders
should choose the correct CPT
procedure code that relates to the
manner in which the lesion was
approached rather than the final
pathologic diagnosis, since the CPT code
should reflect the knowledge, skill, time,
and effort that the physician invested in
the excision of the lesion.
Reporting of Cutaneous Excision
Pending Pathology
FALSE. This WAS the instruction given by CPT in 1996 &
2000; however, in May 2012, this guideline was updated.
 In general, the selection of the appropriate excision code is
determined by three parameters: location, maximum excised
diameter (which includes the margin), and lesion type (ie,
benign or malignant). When the lesion is clearly benign (eg,
cyst, lipoma, prior biopsy of benign neoplasm), the excision
can be coded as benign at the time of surgery (1140011471). When there is a prior biopsy showing malignancy, the
excision can be coded as malignant at the time of surgery
(11600-11646).
 Coding excision of a cutaneous lesion pending pathology (eg,
lesion of unspecified behavior) as malignant before pathology
is available could result in incorrect coding if the lesion is
found to be benign on histopathologic examination.
Therefore, if the lesion is not clearly benign or malignant,
coding and billing should be delayed until the pathology has
been confirmed. ♦

Preoperative Visits CPT Assistant
Archives - Coding Clarification (May
2009), pages 9-10

Pre-operative visits by the surgeon are
always billable, as long as they occur prior
to the start of the global period.
Preoperative Visits

FALSE. If the decision for surgery occurs the day of or day
before the major procedure and includes the preoperative
evaluation and management (E/M) services, then this visit is
separately reportable. Modifier 57, Decision for Surgery, is
appended to the E/M code to indicate this is the decisionmaking service, not the history and physical (H&P) alone). If
the surgeon sees a patient and makes a decision for surgery
and then the patient returns for a visit where the intent of
the visit is the preoperative H&P, and this service occurs in
the interval between the decision making visit and the day of
surgery, regardless of when the visit occurs (1 day, 3 days, or
2 weeks), the visit is not separately billable as it is included in
the surgical package.

Example: The surgeon sees the patient on March 1 and
makes a decision for surgery. Surgery is scheduled for April 1.
The patient returns to the office on March 27 for the H&P,
consent signing, and to ask and clarify additional questions.
This visit on March 27 is not billable, as it is the preoperative
H&P visit and is included in the surgical package.
CPT Assistant Archives - Coding
Brief: Immunization Administration
(90460, 90461) (July 2012), page 7

This service should only be billed when
the counseling is provided by the
physician or a registered nurse.
Immunization Administration &
Counseling (90460, 90461)

FALSE. Codes 90460 and 90461 are reported
only when the physician or qualified health
care professional provides face-to-face
counseling to the patient and/or the patient's
family during the administration of a vaccine. The
term "qualified health care professional" includes
registered nurse practitioners and physician assistants
and these codes may not be reported when other
types of office clinical staff (eg, registered nurses
or other office staff) provide the counseling and
immunization administration.
CPT Assistant Archives - Coding
Brief: Immunization Administration
(90460, 90461) (July 2012), page 12

CPT 90460 may only be reported once
per encounter, as there can only be ONE
initial immunization administration.
Immunization Administration &
Counseling (90460, 90461)

FALSE. Code 90460 encompasses the delivery of
either a single-component vaccine product, which
provides protection for a single disease (eg, hepatitis
B), or of the first component of a multiplecomponent vaccine product (ie, a combination
vaccine), which provides protection for multiple
diseases (eg, diptheria-tetanus-pertussis, hepatitis B,
inactivated poliovirus vaccine [DTaP-HepB-IPV]).
Code 90461 is reported for each additional
component of a multiple-component vaccine beyond
the first component. If a patient were to receive both
types of the vaccines in the example, the
administration code, 90460, would be reported twice.
Immunization Administration & Counseling
(90460, 90461) - EXAMPLE
To illustrate, the list of codes that would be reported for a 2-month-old infant
based on the current immunization schedule is as follows:
DTaP intramuscular administration
90460, 90461, 90461
90700 (CPT product code to be
reported in addition to the
immunization administration codes)
Rotavirus oral administration
90460
90681 (CPT product code to be
reported in addition to the
immunization administration code)
Hepatitis B and Haemophilus influenza
90460, 90461 (2 components)
type B intramuscular administration
90748 (CPT product code to be
reported in addition to the
immunization administration codes)
Evaluation & Management

None of the 1997 documentation
guidelines can be used in conjunction with
1995 documentation guidelines.

http://www.cms.gov/Medicare/MedicareFee-for-ServicePayment/PhysicianFeeSched/Downloads/E
M-FAQ-1995-1997.pdf
Evaluation & Management




FALSE. Effective Sept. 10, the CMS allows physicians to use the
1997 DG for an extended history of present illness (HPI) with the
other elements of the 1995 DG to document an E/M service. As a
result, “the status of three or more chronic conditions” qualifies as
an Extended HPI for either set of DGs.
The revised guideline is presented as a Question and Answer on
the CMS website: FAQ on 1995 & 1997 Documentation
Guidelines for Evaluation & Management Services.
Q. Can a provider use both the 1995 and 1997 Documentation
Guidelines for Evaluation and Management Services to document their
choice of evaluation and management HCPCS code?
A. For billing Medicare, a provider may choose either version of the
documentation guidelines, not a combination of the two, to document a
patient encounter. However, beginning for services performed on or after
September 10, 2013 physicians may use the 1997 documentation
guidelines for an extended history of present illness along with other
elements from the 1995 guidelines to document an evaluation and
management service.
HPI Documentation

Does the provider have to document the
HPI (history of present illness)?
HPI Documentation
GOOD QUESTION!
1995 & 1997 Documentation guidelines
state that the ROS and/or PFSH may be
recorded by ancillary staff or on a form
completed by the patient. To document that
the physician reviewed the information,
there must be a notation supplementing or
confirming the information recorded by
others.
 Because the DG’s do not specifically state
the HPI can be documented by ancillary staff,
it is assumed that the provider must do this.
However, the guidelines themselves DO
NOT state this!


HPI Documentation - Noridian

Noridian’s E&M Clarification posted on
05/21/2007 indicates their expectation is
that the provider will gather and record
this information.

https://www.noridianmedicare.com/cgibin/coranto/viewnews.cgi?id=EEZAZlkyFy
xzeFsPmT&tmpl=part_b_viewnews&style
=part_ab_viewnews
https://www.noridianmedicare.com/cgibin/coranto/viewnews.cgi?id=EEZAZlkyFyxzeFsPmT&tmpl=part_b_viewnews&style=part_a
b_viewnews
Documentation Guidelines, E/M
Documentation When History Is Not
Available (Q&A), January 1998, page 10

Documenting E/M services and unresponsive
and comatose patients. If the physician
cannot obtain the history due to the
patient's condition but does a
comprehensive exam and the medical
decision making is of high complexity, is this
reported as a level three or not, since the
history was not obtained (even though the
reason he couldn't perform the history is
documented)?
E/M When History Is Not Available
AMA Comment

In those circumstances when the patient's nature of illness/injury
does not lend itself to eliciting a history nor is it available from
either a SNF or other hospital transfer sheet, the patient, family,
significant other, or other source, or by performing a
comprehensive examination, the physician should document in the
medical record the circumstances which precluded obtaining this
information or from doing the comprehensive examination. This
shows a good faith effort on the part of the physician. The July 1997
edition of the CPT Assistant, page 5, A. Documentation of History,
second column, second DG bullet states:

DG "If the physician is unable to obtain a history from the patient
or other source the record should describe the patient's condition
or other circumstance which precludes obtaining a history."
CPT Assistant Archives - Surgery:
Digestive System (June 2006), page
16c

Is it appropriate to report CPT code
45915, Removal of fecal impaction or foreign
body (separate procedure) under anesthesia,
when conscious sedation is used?
Digestive System

NO. CPT code 45915 is intended to be reported
for fecal impaction or foreign body removals only
when performed under general anesthesia. The
CPT code descriptors that include the phrase
"requiring anesthesia" or "under anesthesia"
indicate that the work involved in that specific
procedure requires the use of general anesthesia;
therefore, it would not be appropriate to report
code 45915 if general anesthesia is not provided.
Fecal impaction or foreign body removal
performed with other anesthetics is
considered inclusive to the appropriate
evaluation and management service code.
CPT Assistant Archives - Surgery:
Auditory System (July 2005),
page 14

Cerumen removal can only be billed if the
documentation records an impaction,
instrumentation is used, and it is
performed by a physician.
Auditory System

CORRECT. Removing wax that is not impacted does
not warrant the reporting of CPT code 69210.
Rather, that work would appropriately be captured by
an evaluation and management (E/M) code regardless
of how it is removed. If, however, the wax is truly
impacted, then its removal should be reported with
69210 if performed by a physician using at minimum
an otoscope and instruments such as wax curettes or,
in the case of many otolaryngologists, with an
operating microscope and suction plus specific ear
instruments (eg, cup forceps, right angles).
Accompanying documentation should indicate the
time, effort, and equipment required to provide the
service.
National Drug Codes

When there is a 10 digit number listed on
the drug insert, you should always add a
“0” at the very beginning of the code to
make it the 1 digit number that is
required.
National Drug Codes
FALSE!
 There are 3 segments to an NDC
number that identifies the labeler, product
and trade package size. Each segment is
divided into sets of 5-4-2.
 If the NDC# from the supplier is only 10
digits long, you will need to add a “0”, but
it can be added in front of any of the digit
number sets.

National Drug Codes
The first segment indicates the labeler
code and is 4 or 5 digits long.
 The second segment indicates the
product and specifies the strength, dosage
and formulation. It is 3 or 4 digits long.
 The third segments is the package
segment that identifies the package form
and sizes. It consists of 1 or 2 digits.

National Drug Codes
For example:
5……4 …2
XXXX-XXXX-XX = 0XXXX-XXXX-XX
XXXXX-XXX-XX = XXXXX-0XXX-XX
XXXXX-XXXX-X = XXXXX-XXXX-0X

FDA-Food and Drug Administration NDC Website
http://www.accessdata.fda.gov/scripts/cder/ndc/default.cfm
Trade
Name
Strength Complete
NDC
Famotidine
Injection
200
mg/20ml
Pack/Size Type
10019-046-01 20 ML
Vial
Doseage
Form
RX/ OTC
IV
R
Using our 5-4-2 formula, where would the “0”
need to be inserted
for this drug?
RAC Audits
When you have a redetermination for the
RA (or any other post pay audit
contractor), you cannot file a claim
determination if it is over one year old.
 Example: RAC audit indicates New
Patient Visit was billed in error. Claim is
from 2010. Since the initial visit date is
over one year old, you must return the
money and cannot re-bill a corrected
claim for an established patient visit.

RAC Audits
FALSE!
 You should not bill a corrected claim, but
instead use the appeal process.
 Make sure to mark the RA box on the
interactive Redetermination, so that
timely filing can be waived. Providers have
120 days from the initial demand letter to
submit the redetermination.

Established Patient Visit?

If a physician has provided an
interpretation for a study at the hospital,
and then sees the patient in the office for
the first time, this should be billed as an
Established Patient Visit.
Established Patient Visit?




FALSE:
The guidelines state the service is within the past
3 years by the same provider or by the same
specialty, within the same group. This guideline is
explained in
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c
12.pdf Section 30.6.7A.
Exception: The interpretation of a diagnostic
test, x-ray reading or EKG, etc., without an E/M
or other face-to-face service does not affect
the designation of a new patient.
THANK YOU!!