1. L

    Question Interprofessional Consults

    Hello, I have been going back and forth on this one question a provider asked. I hope someone can help. If a provider does an Interprofessional consult on a patient and 4 months down the road, the patient schedules an apt. to see that specialist, is that patient considered a new or established...
  2. E

    Wiki Why was I marked wrong? (Practicode Case ID: OPD7085)

    The documentation: Why is the MDM low? There was prescription drug management, combined with discussion with another provider.
  3. E

    Question Why was I marked wrong? (Practicode Case ID: OPD7419)

    The documentation: Why aren't the hypertension and smoking reported?
  4. E

    Wiki Why was I marked wrong? (Practicode Case ID: OPD7420)

    The relevant documentation: Why isn't the CT scan reported?
  5. A

    Wiki APRN and PA Hospital Billing

    Hi there! I work at a cardiology group that currently has 12 physicians and one APRN and one PA. I was questioned by one of my physicians today on how to go about coding hospital consults and followups when the physician AND the APRN were together physically seeing each patient. How would these...
  6. L

    Wiki MDM with 2 history of codes

    I am trying to figure out E/M level here... I was told 2 history of diagnosis are considered stable chronic. So this would be a 99214 due to that and data points. Is this accurate? history of codes being "counted" this way? Can anyone provide any resources? Thank you in advance!
  7. S

    Wiki Swing Bed E/M Admit Documentation

    There is an issue on what documentation is required to code an admit E/M level when a pt is discharged from IP or observation (obs) to swing bed in the same facility. *Our providers are trying to use the H/P (from IP or obs admit) for the swing bed admit. Ex) pt admitted to IP on...
  8. E

    Question Why was I marked wrong? (Practicode Case ID: OPD7411)

    The documentation: Doesn't the X-Ray (interpreted by the radiologist) count as independent interpretation of tests? Also, the guidelines say that fulfilling just one of the three categories in that MDM element is enough for that element to be moderate. Then combined with the prescription drug...
  9. A

    Question E/M with Debridement in Wound Care Clinic

    Hello, Does anyone have further clarification on when it is appropriate to bill an E/M with a debridement performed on the same wound and in office, pos 11. Guidelines state they can be billed if a reasonable and necessary office visit is provided and is separately identifiable from the...
  10. L

    Wiki Modifier 25 , E/M with minor procedure

    I thought I would get people's thoughts on adding an E/M to a minor procedure (cysto). I keep going back and forth on what would be correct. Pt comes in for scheduled Cysto due to BPH luts, they are able to determine severity of enlargement and after the procedure they discuss possible options...
  11. J


    Hello, if a doctor does an interp of 2 tests (CT scan and MRI), does that count as meeting "2 categories" because he did two different interps or does it still only count for "1 category"? I used the AAPC e/m calculator and it would not allow me to select "2" for that category so I am leaning...
  12. P

    Wiki Medical Decision Making Risk: Morning after pill (Emergency Contraceptive)

    Hello, We are a family planning specialty. Hope I could get a clarification on the MDM risk when provider prescribes a morning after pill (1 tablet). Is this considered as prescription management? Is truly managed when it is considered an emergency contraceptive and not for recurrent use? And...
  13. K

    Wiki E/M when Criteria not met?

    If a patient comes in, but they don't meet the criteria to bill for routine foot care procedures (i.e. nail debridement, callus removal, etc.), can I still bill out an office E/M (i.e 99212) since the patient was still seen and examined and was educated on their diabetes status and what to look...
  14. P

    Wiki E/M MDM Question on chronic conditions unrelated to CC

    Hello, we are a family planning specialty so most of our patients are seen for STI / Infection checks with symptoms such as discharge, painful urination, lesions, etc... If provider included chronic conditions such as elevated BP, hypertension, obesity that are not related to the chief complaint...
  15. A

    Wiki 99211 with an Office Visit E/M

    The patient was seen by the nurse for a PPD skin test placement and then by the doctor for a typical office visit. In the office visit the provider mentions that the patient received the skin test on that day and the documentation read was ordered. My understanding is that two E/Ms cannot be...
  16. T

    Wiki Same group/2 APPs/2 E/M visits on same DOS

    We have a scenario where 2 different APPs are providing E/M services to the same patient on the same day, ex: APP 1 sees patient in morning for consultation. APP 1 leaves for the day so APP 2 follows-up that evening to follow up on additional imaging, explain an additional procedure and measure...
  17. T

    Wiki External physician/other qualified health care professional/appropriate source

    For 2023 inpatient coding on MDM, the data section in category 3 is discussion with external physician/other qualified health care professional/appropriate source- does a nurse (RN) working on the patients floor count as a 'other qualified health care professional/appropriate source' (my...
  18. A

    Wiki G0317 Prolonged Service, how to bill

    Do you have to bill the prolonged service G0317 on the same claim form as your E/M visit, (99306-99310) or can this code be billed separately on it's own?
  19. jkyles

    Wiki 2023 E/M guidelines

    The guidelines that will go into effect 1/1/2023 are available. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Enjoy! :geek:
  20. J

    Wiki Do in office procedures count toward MDM column 3?

    If a physician decides to give and bill for an injection during an office visit does this count toward the MDM (column 3)? Patient presented with plantar fasciitis which is progressing in pain over the past several months. The provider then performed below injection: "At this time, the foot...
  21. K

    Wiki Bacteremia

    Hello, Is bacteremia considered high risk on the table of risk chart? The provider is treating the bacteremia with IV antibiotics.
  22. A

    Wiki Depression and Anxiety Screenings (96127)

    Do you charge for screenings for anxiety and depression (96127X2) if they are done during every psych visit (99202-99205 or 99212-99215)? I feel that these would be part of the E/M since they are done on every patient in the psych clinic, but I was wondering what views others had.
  23. B

    Wiki Telehealth E/M Codes + Modifier Requirements

    I am looking for coding scenarios/examples on which E/M codes to assign for telehealth visits at a provider based facility. (We are a CAH with a family medicine clinic, majority of telehealth is the family health clinic) Based on what I'm reading in my CPT book, we should be using the 9944x...
  24. KStaten

    Wiki Recommendation for Dental prophylaxis Following Joint Replacement- MDM

    Hello, Everyone. :) Dental prophylaxis is often recommended for patients following joint replacement, whereas any vulnerable areas for infection in the body can pose a potential risk. If, however, the doctor documents-- in a routine, yearly exam-- that there are no problems with the...
  25. C

    Wiki E/M Consultation - CPC exam prep question - help

    I am sitting for my CPC exam on Saturday. There is a question in the Study Guide that has me stumped (and my two CPC colleagues too). A 55-year-old patient is seen in an office visit by an otolaryngologist. Dr. Nettles, at the request of her primary care provider for sudden hearing loss. The...
  26. KStaten

    E/M Level for Pain Following Hip Replacement (Outside Global Period)

    Hello, everyone. :) Does anyone think this would justify a 99213 with the new guidelines or would it only meet the requirements for a 99212? (Input is greatly appreciated!) -------------------------------------------------------------------------------------------------------------------------...
  27. K

    Wiki E/M and Procedure same day, New patient

    If a patient is referred to us for Epistaxis R04.0 and we have never seen them before, we do the E&M and it is decided that the patient needs a scope. Can we bill a new patient visit and a scope on the same day 99204 with a 25 modifier 31231 Nasal Endoscopy?
  28. J

    Wiki Modifier 27 help

    Hi all! I'm looking for resource material regarding the use of Mod-27. I code for an ED with affiliated Primary and Specialty Care offices and Walk-In's. At some point, someone in my organization advised we could not use Mod-27 with ED E/M's when a patient has an additional outpatient visit that...
  29. KStaten

    Wiki Are Medicare's Guidelines for E/M CPT Codes the same as AMA's?

    Hello, Everyone. :) I would greatly appreciate it if you could please share documentation that shows how "closely" Medicare bases its guidelines in comparison to AMA's rules/ guidelines regarding levels for E/M-- specifically, the MDM table. 😐 It has recently been suggested to me that the rules...
  30. M

    Wiki Observation Codes and POS 21

    Hello, can observation codes be billed under POS 21?
  31. morganscott

    Wiki AMA in the ED

    When a patient leaves AMA (against medical advice), can an E/M level be applied? Can you bill for ED charts when a patient leaves AMA? (Critical Access Hospital)
  32. KStaten

    Wiki MDM for Total Hip / Knee Replacement

    Hello Everyone. :) I have gone down a rabbit hole on coding joint replacement surgeries and would 💙GREATLY APPRECIATE💙 your input for confirmation, given the 2021 E/M guidelines. I apologize in advance for the redundancy of this question. A ) In the plan, it is documented that a 65-year-old...
  33. S

    Medicare Split Visit Question

    There is some confusion of when it is appropriate to split a visit for Medicare IPPE/Initial or Subsequent AWVs utilizing the new E/M MDM if not based upon time for each (IPPE/AWV vs OV) Can a visit be split if all other Medicare requirements are met and the patient has 2+stable chronic...
  34. G

    Wiki E/M level

    Our surgeon wants a 99205/99215 for these visits. We cannot seem to find the documentation supporting these levels. Wondering if maybe we are missing something? We are also asking so we can have information from somewhere besides us (coders) to support our decision when trying to educate the...
  35. N

    Wiki Unrelated E/M with procedure

    Hi, general question... Is it appropriate to bill an E/M -25 when its unrelated to the primary procedure on every visit? It's not bundled due to both codes being unrelated. For example, patient comes in for debridement 11042 on right ankle, but provider treats edema in another area which is new...
  36. N

    Wiki Bundled Office Visit w/ -25

    We have been getting denials recently from Humana when billing 99214-25 (I70.233, F17.218, I89.0) 11042 (L97.312, L97.212, T81.31XA) Dx are different for each code. Only thing I can think of is the i70.233 and L97 codes both address the 'right leg' .. BUT we have been getting paid before with...
  37. KStaten

    E/M for Biceps Rupture

    Greetings Fellow Coders :) Since the E/M level is now based upon MDM only, I have been noticing that providers are still in the habit of billing with the old guidelines in mind, which in some cases, would result in higher levels of E/M. I would really appreciate if others can help me out by...
  38. M

    Wiki 99211 on same day as injection and pregnancy test

    Hello coders! Please help clarify so I can settle the dispute with the NP and WHNP in my office. A patient came in and was seen by the CMA for pregnancy test and depo injection. The pregnancy was negative. Can we bill a 99211 with the depo injection and the pregnancy test? Please explain...
  39. M

    Wiki Do you add MOD 59 to a sono with a Comp (99385) visit?

    Hi, Pt came in for Comp visit 99385 with a pap (Q0091) and TV sono (76830) 99385-25, Q0091, 76830-59? Thank you
  40. KStaten

    Wiki Repeat Injections with E/M Codes

    Greetings Fellow Coders! :) Scenario: A new patient is evaluated and found to have OA of the left knee. On that visit, the physician decides to perform an injection and bills an E/M (99203) with a modifier 25. At that visit, the physician does not "plan" another injection. If the patient...
  41. KStaten

    Wiki Documentation Requirements for Components of E/M

    Hello Everyone! With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends...
  42. L

    Wiki Using vitals dated the day before on a 99211

    I work for a residential BH company that also provides medical services to the residents. Because the patients are living in such a close environment, the nurses are doing vitals daily, in the evening. The next day, when they bill 99211, the vitals are dated the day before. They were told that...
  43. J

    Wiki New Patient E/M with injection 20610

    We are finding that new patient office visits billed with injections are being denied as not medical necessary. The injection is being paid . An office visit is performed and Patient is new. 99203,25 was billed with 20610 and the J code Should the 99203 be down coded to 99202 when an...
  44. J

    Wiki MD and Physical Therapy same day

    Can a patient have an appointment with the MD with xrays on the same day as physical therapy? Same facility different providers.
  45. G

    Wiki No qualifying visit?

    Provider is wanting a 99202 for this visit. I do not feel this visit has enough documentation for a qualifying visit. Does anyone see something I may be missing? Thank you Primary Care Provider: Accompanied by: Self Visit Type: New Visit Chief Complaint: Estab care- Requesting labs History...
  46. J

    Wiki Aetna Medicare Mid-Level E/M

    Our office is having problems with Aenta Medicare (specifically Aetna Medicare Elite and Premier) denying our Physician Assistant E/M charges stating the provider type is ineligible to bill/perform the service (PI-170). They will pay other services on the claim, if any, (like a UA, EKG, etc) but...
  47. KStaten

    Wiki Coding / Billing Audio-Only Telehealth Visits

    Hello Everyone! :) Here's my silly question for the day. (Brace yourselves, as I am sure more are to come. ;) ) As I have interpreted from articles, the accepted Telehealth services have been expanded to include audio-only telephone calls, as well. (Yay!) Now this is the part where I am...
  48. T

    Question Physical exam in a Telehealth visit

    Does anyone have information about documenting physical exam for established patient telehealth visits billable using 99201-99215? It would seem a limited exam could be documented based on physician observations during the call. I know it isn't technically required (2/3 elements and all that)...
  49. A

    Wiki Acceptable ROS/PFSH notation?

    My provider usually documents ROS/PFSH for establish patients as such: PAST MEDICAL HISTORY, SOCIAL HISTORY, MEDICATIONS AND ALLERGIES: Reviewed and not changed since last visit. REVIEW OF SYSTEMS: Reviewed in chart and signed. Per E/M guidelines, the provider has to indicate that the...
  50. C

    Wiki 2021 E/M Documentation Changes - What are your EHR vendors saying

    Good afternoon AAPC members. I am working to find out if anyone out there is in discussion yet with your EHR Vendor about the changes for 2021 E/Ms. If so, would you mind sharing the name of your EHR Vendor and their level of preparations? Thank you!! Carol J. Self, CPPM, CPC, EMT AAFP