Part B Insider (Multispecialty) Coding Alert

Published on Thu Jan 01, 2004 PDF

Exhaust all other E/M options before reaching for unspecified code 

When you don't know what other E/M code to bill, it's tempting to reach for the unlisted E/M service code, 99499.
 
But this code is hard to justify and even harder to receive payment for, coding experts say. "99499 is used when no other code in the E/M section describes the services rendered," says Jaime Darling, a coder with Graybill Medical Group in Escondido, Calif.
 
"The best documentation for using this code is usually in the form of a letter from the physician that describes the service and the reasoning behind the requested reimbursement," Darling adds. "Since there is no specific fee attached to unlisted-procedure codes, it's up to the physician's office to request appropriate reimbursement."
 
You can do this in a few ways, says Quinten Buechner, president of Proactive Consultants in Cumberland, Wis. You can suggest a similar code to the payer, mention what you consider an appropriate price for the work you've done, or send in the entire note pointing out difficult sub-procedures or things that required extra skill. It's also important to discuss why you couldn't use a regular CPT code.
 In general, you need to appeal claims for 99499 or send them directly to a medical review board, and reimbursement may take a little longer to arrive, Darling says. "But if the documentation/report from the physician is clear, then there should be no problem getting reimbursed."
 
The main reason you'd use 99499 is for a new patient visit in which a nurse sees the patient and the doctor doesn't, or when you don't have enough documentation to meet the standards for a level-one office visit (99201). Even with enough documentation, some carriers may decide these aren't reimbursable services, Darling says.
 
George Ward, billing supervisor with South Of Market Health Care in San Francisco, has had no luck getting Medicare to pay for 99499, but some other payers will. He suggests calling your Part B carrier or other payer to find out if they cover the code. If you think your carrier may not reimburse the code, make sure to give your patients an advance beneficiary notice beforehand so you can bill the patient after the claim is denied.
 
You wouldn't need to use 99499 for an established patient visit that fails to meet the three criteria for E/M, because you can use 99211 for that, Ward says.
 
If your practice is using 99499 regularly, it could be a red flag for an audit, Darling says. "These codes tend to be most commonly misused when physicians aim for higher reimbursement for E/M services when another code better describes the service."
 
For example, physicians will use them instead of an E/M and a prolonged service code when they've spent extra time with a patient, or for coordination of care when a patient wasn't present. People sometimes mistake 99499 for a "catchall" code, Darling says.
 
You should become intimately familiar with all the possible E/M codes and explore all other possible avenues before choosing 99499, Darling says.