Q: When is it appropriate to report a consultation code vs. a new patient office visit code or other E & M code?
A: In general, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by a physician or other appropriate source. Given that definition, how does CPT define "other appropriate source"? The guidelines do not specify nor restrict who may be considered an "other appropriate source." However, examples of appropriate sources might be a school nurse, physician extender, physical, speech or occupational therapist, insurance company, or lawyer. It is important to note that the patient or family are not considered appropriate sources

Q: When counseling is used as the determining factor in choosing an Evaluation and Management code, what are the times associated with the different levels of service?
A: Problem Visits Codes and Counseling: CPT description of the problem visit codes contains a descriptor for each code based on time. "Physicians typically spend X minutes face-to face with the patient and/or family."  When more than 50 % of the total time spent with the patient and/or family is dominated by counseling or coordination of care, the CPT code may be chosen based on time alone. Choose the code for which the total time of the visit meets the "typical time" described in CPT. Total time, counseling time and subjects about that the patient and/or family were counseled must be documented in the chart. These codes are to be used when there is an established illness.

An example of the documentation statement required to bill a problem visit based on time follows. More than 50% of this XX-minute visit was spent counseling the patient and family about ________.

Q: A patient is being seen by one physician in a group practice. During the course of the visit, an unrelated medical issue is discovered. The treating physician sends the patient to another physician in the same group practice of a different specialty for evaluation. Is the visit for the second physician considered a New or Established?
A: In this scenario the patient would have new patient status. By CPT definition; A New Patient is one who has not received professional services within the past three years from the physician or another physician of the same specialty and group practice.

Q: When is casting a billable procedure?
A: Per CPT, the procedures listed in the Application of Casts and Strapping section apply when the cast application or strapping is a replacement procedure used during or after the period of follow-up care, or when the cast application or strapping is an initial service performed without restorative treatment to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient.

Q: Is code 90801, Psychiatric Diagnostic Interview Examination, to be reported for the Initial Interview only or can it be reported during a course of therapy?
A: Code 90801, Psychiatric Diagnostic Interview Examination, does not indicate that this code is only to be reported at the initial encounter with the patient.  The NHIC Medicare LCD states that the code is used primarily during the initial phase of treatment. The LCD does not indicate that it should be reported exclusively at the initial encounter but during the initial phase. This LCD does state, however, that this code should be reported only once during an inpatient hospital admission

Q: If "rule outs" cannot be used as a billing diagnosis, how do the physicians communicate to the billing office that the reason for the visit is to "rule out" a certain condition? E.g. rule out chondromalacia or rule out Hep B.
A: The condition of the patient should be coded to the highest degree of certainty at the conclusion of the visit.  The ICD-9-CM coding system has not assigned codes for probable, suspected, questionable or rule out conditions. Rule out, suspected and questionable conditions cannot be coded as if the conditions exist. The signs ands symptoms that brought the patient to the practice should be coded if a definitive diagnosis has not been established.

Q: What may a provider include when calculating the time to code a Discharge Day; CPT Codes 99238, Hospital Discharge Day Management; 30 minutes or less and 99239, Hospital Discharge Day Management; more than 30 minutes? Can the attending take into account the house staff's time as well as lactation consultant and breast feeding class/instruction?
A: Per CMS. "The hospital discharge day management codes are to be used to report the total duration of time spent by the physician [emphasis added] for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that day is not continuous, instructions for continuing care to all relevant care givers and preparation of discharge records, prescriptions and referral forms."

Only those services performed by the billing provider may be totaled to appropriately code the Discharge Day Management. Total duration of time spent by the physician for final hospital discharge of the patient is reported even if the time spent by the physician on that date is not continuous.

Q: Can we utilize the Locum Tenens policy or the "Incident to" policy to allow billing for new doctors during the credentialling process for Provider billing numbers? Is there a time limit to the use of the Locum Tenens policy?
A: Neither the Locum Tenens nor the Incident to policies can be applied to the frequent situation of credentialing delays.

Locum Tenens cannot be applied to this situation as it fails to meet the following three criteria required to invoke this policy. Locum Tenens has a time limit of 60 consecutive days.

• The regular physician in unavailable to provide visit services.
• The patient seeks services from the regular physician.
• The substituting physician is paid per diem or fee for-time-basis.

The Incident to services policy cannot be applied to this situation because the service provided by the "new" doctor is not;

• Auxiliary personell nor a "practitioner" as defined by CMS (PA,NP,CNS, CNM)
• an integral part of another doctor's diagnosis or treatment
• provided under the direct supervision of another physician

Q: When two physicians in the same group are involved in an inpatient admission, can both bill for the inpatient admission codes (99221-99223)?
A: No, only one physician may bill for the inpatient admission even if the physicians are of different specialties. The following is an excerpt from the Medicare Carrier's Manual.
                                   
Initial Hospital Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission.--Advise physicians to use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician.

Consider only one M.D. or D.O. to be the admitting physician and permit only the admitting physician to use the initial hospital care codes.  Advise physicians that if they participate in the care of a patient but are not the admitting physician of record, they should bill the inpatient evaluation and management services codes that describe their participation in the patient's care (i.e., subsequent hospital visit or inpatient consultation).

Q: When may I bill for Evaluation and Management services during a global surgical period? When is it appropriate to append modifier 24?
A: Surgeries, both major and minor, have global periods in which services related to the recovery from the surgery are considered included in the allowance paid for the surgery itself.

Modifier 24 is defined as an "Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier '-24' to the appropriate level of E/M service. Modifier 24 is only appended to Evaluation & Management codes."

Do not use modifier 24 for E&M services during the global period if they are rendered for;

1) Conditions related to the body area/organ or incision area of the surgery
2) Conditions that would not have existed without the surgery i.e. complication from the surgery
3) Conditions that are a direct result of the surgery.