Primary Care Coding Alert

Question: How do we designate different levels of preventive care? Maybe someone only needs a blood pressure taken or a cholesterol check vs. an extensive annual physical?

Anonymous Ohio Subscriber

Answer: If a 50-year-old female patient needs a blood pressure or blood cholesterol check, this may be the result of a chronic condition follow-up visit for hypertension or hyperlipidemia (excess of fat or lipids in the blood), says Jean Stoner, CPC, manager, coding operations for CodeRyte, a coding software company in Bethesda, Md.

If the patient has hypertension, for example, and comes to the family physicians office for a blood pressure check performed by the office nurse, then at best you can bill 99211 (office or outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, five minutes are spent performing or supervising these services). Be sure that this is a medically necessary service and ordered by a physician.

If the patient has hyperlipidemia, she may come to the office for a blood draw to check cholesterol. You should bill only 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). If the family doctor also reviews the patient's medicines and checks to see how she is doing, the appropriate level of office visit, 99212-99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging from a problem-focused to a comprehensive history; a problem-focused to a comprehensive examination, and a straightforward medical decision to one of high complexity) may also be billed.

Don't bill 99211 with 36415 just because the nurse performed a blood draw, Stoner says. If your office performs the lab analysis, bill lab code 83718 (lipoprotein, direct measurement; high density cholesterol [HDL cholesterol]), 83719 (lipoprotein, direct measurement; VLDL cholesterol) or 83721 (lipoprotein, direct measurement, LDL cholesterol).

A blood pressure or cholesterol check also may be a limited preventive screening service. If a nurse is providing a screening blood pressure check, you could bill 99211, but you may run into medical necessity denials from insurance companies and end up having to bill the patient or write off the charge, Stoner says.

If a physician conducts the blood pressure screening, however, and also discusses diet and exercise and takes at least a brief history, you can bill an office visit. Since no examination or decision-making took place, the key ingredient becomes time, the American Medical Association (AMA) says. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and or family encounter (face-to-face time in the office or other outpatient setting or [...]