97802-97804 - Medical Nutrition Therapy Procedures
If the MD documents review of Medical Nutrition Therapy 97110 or rehab 97001 on an inpatient note, would you count that in complexity of data as 1 point for review of Medicine section CPT 90701 - 99199? Does the CPT have to be a "test"? The CPT range on the AAPC audit form includes therapies the MD would need to see results of for medical necessity. If not, would you count as obtain hx from someone other than pt - 1 point?
The codes you listed above:
97110 - The physical therapist or the healthcare provider spends 15 minutes with the patient and guides him/her in performing therapeutic exercises.
97001 - Physical therapy evaluation
97802 - Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803 - Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804 - Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes
(The provider, typically a qualified nutrition professional, assesses the medical condition of the patient, performs a nutrition screen, and initiates a specific dietary plan for the patient).
No. The physician did not order medication or review medication the patient is already taking.
No. Review and summary of
old records and/or obtaining hx from someone other than patient and/or discussion with other health provider.
I was taught that you would only obtain a hx from someone other than patient (i.e. family member, care taker) when there was a specific medical reason the pt could not provide the hx themselves. This needs to be clearly documented w/in the medical record. The physician had to go to greater lengths to obtain this information. That is why it warrants a higher point value.
I went ahead and included examples below.
Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document the history (if any) that is available.
We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient's family or others to obtain history, document the work performed and code based on the work performed. The use of the NOC (99499) should be very rare.
http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml
https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf