Coding Pearls for Primary Care

By Stephen C. Spain, MD, FAAFP, CPC

Hardworking Dr. Smith is visibly troubled as she pushes the letter across her desk for you to read. She summoned you, the office coding specialist, shortly after she received the certified letter from ACME insurance company. You carefully digest each word of the letter, which ominously informs the doctor that an auditor will be arriving soon with a list of beneficiary charts to review. In a situation such as this, would you be overcome by anxiety, or would you be confident in the knowledge that your practice’s documentation and coding practices are in compliance with payer rules?

Most primary care physicians are too focused on providing patient care to be able to master all the nuances of coding and reimbursement that are the bread and butter of coding professionals. It is important for the coder or auditor to work with the providers to identify areas where services are being overlooked or miscoded, and to jointly formulate a plan to help capture lost revenue and lessen the possibility of an audit. The purpose of this article is to help coders identify several common areas where improper coding may have a significant impact on reimbursement or cause unwanted exposure to a payer audit.

Watch Those Units

Whether counting skin lesions or drug units, it always pays to be precise. Be sure your providers understand the importance of giving you precise information wherever a count is necessary, and help them understand the cut off points for reimbursement. For example, if a patient presents for the removal of multiple skin tags, there is a big reimbursement difference between removing 15 and 25. If a patient has 25 or more to be removed, it makes sense to remove them all, rather that just the largest 10 or 12 lesions. Similarly, for actinic keratoses, two lesions pay better than one, and 15 lesions pay better than 14.

If your superbill just lists drugs and does not prompt for units, be sure the physician fills in the quantity of units wherever necessary. If a gram of Rocephin is given, and only one unit (250 mg per unit) is billed, 75 percent of the revenue is lost, which means that the practice is actually losing money on the drug inventory. One large group practice recently learned that they had missed a payer units change for a common injectable that had occurred years earlier. Although the difference in reimbursement was only about 60 cents per injection, it was easily calculated that the impact to the group for years of improper billing was thousands of dollars!

Don’t Forget the Ear

Many new providers are not aware that removal of cerumen from the ear is a billable service. It must be done by the provider, not the nurse, but the payment is usually in the $40 range. This reimbursement, on top of the E/M service, makes the struggle with little Johnny to properly diagnose that middle ear infection well worth the effort. Of course, adults are much more cooperative and appreciative when their hearing is suddenly restored! When billing 69210 (Removal impacted cerumen (separate procedure), one or both ears), be sure that the modifier 25 is added to the E/M service.

Understand I&D

MRSA skin abscesses are on the rise in primary care offices, so proper coding of their treatment is important. Most physicians will have a very different view of complicated I&D than stipulated by coding criteria. Any abscess that requires follow up, dressing changes, serial packing or other ongoing care is considered a complicated lesion, and should be coded 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple). Be alert to those that require return visits, and be sure they are coded as 10061 from the outset. For new patients, the E/M service can almost always be charged, with modifier 25. For established patients, an E/M service is often applicable if the provider has included the history of the lesion, the absence or presence of systemic symptoms, and documented instructions for antibiotics or pain medications.

Bill for Medicare Preventive Services

Because coverage of preventive care services with private payers is so varied, many providers perform the services but shy away from billing them as such. This attitude is carried over to Medicare patients, as well. However, many preventive care services are generously covered for Medicare beneficiaries. It is important that your providers understand these preventive care rules and guidelines because the rewards are significant. In addition, preventive services can be billed along with E/M codes for the same-day visit, provided the documentation is complete.

Medicare pays about $40 for an annual rectal exam (G0102) for males over 50. For women, a biennial preventive gynecologic exam (G0101) is also reimbursed about $40 with no deductible. Three to 10 minutes of smoking cessation counseling (G0375) is reimbursed at about $12, and more than 10 minutes (G0376) pays over $20. These counseling fees can be billed up to eight times per year. The allowed charge for the “Welcome to Medicare” exam (G0344, Initial preventive physical examination) is around $90, and additional fees are allowed for an EKG (G036x). This evaluation must include certain key elements, such as an assessment of depression risk, and aortic aneurysm evaluation for beneficiaries at risk. The requirements are not onerous, and practice income can be substantially increased by identifying the qualified Medicare patients and providing the services with proper documentation.

Monitor Inpatient Care

If your providers perform inpatient care, be on the look out for a pattern of incorrect use of the 99232 and 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …) inpatient daily care codes. These codes are for patients with conditions not responding to therapy, who have developed new complications, or who are unstable. For patients who are “stable, recovering or improving,” the correct code is 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient). It is a red flag to auditors to see a string of 99232 and 99233 visits capped off with a 99238 (Hospital discharge day management; 30 minutes or less) discharge management code. Most non-intensive care hospital patients are improving, so the bulk of daily care charges should be of the 99231 variety.

As coding and documentation rules have become more complex, providers are now increasingly dependent upon their coding staff. This dependence places additional responsibility on the shoulders of the coding professional. Stay abreast of changes and alert to patterns of misuse or abuse. Do your best to maintain open channels of communication with providers, so that you can alert them to changes in requirements, and point out areas of incomplete documentation or inappropriate coding. Once you have identified areas for improvement or change, discuss them with the providers and agree on a plan of action and ongoing monitoring. This partnership with practice providers is essential to both protect the practice from dwindling reimbursement and to withstand the increasing pressures of payer scrutiny.

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