Many questions as a newly employed CPC-A

CPCA2016

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I am a CPC-A as of December 2015 and am proud and happy to say I have been working since January of 2016. First remotely for a few months and now I am working as a coder for a medical billing company. We bill for 18 different providers of various specialities and I get access to many different types of encounters. I have many questions in regards to what I have learned vs how it really works in the real world!

If a patient comes in for a B12 shot and does not see the physician what are the correct codes? I have been doing 96372 and J3420. Now I was initially coding 99211 with that as I was taught that is a nurse visit but then I read, on here somewhere I believe, not to bill 99211 w/injections. So which is correct?

Same scenario as above but patient does see the physician but nothing else is documented but the B12 shot; what are the correct codes for that? The same? Being that a complete office visit is not done or documented; just the B12 shot.

And on this note, when would you bill 99211? When will a patient come in only to see the nurse and not get an injection? Maybe a blood pressure check?

This one has me really stumped. A patient who broke his leg up north, had a cast put on up north, now home and wants a 2nd opinion. The provider sees this patient for the first time (weeks after the initial cast was put on; by another provider mind you) and sends him for X-rays and reads them immediately and fracture is healed so this provider removes current cast with anesthesia for cast removal, and applies another cast (not sure if this is a walking boot or what-waiting on more clarification from the office) and orders PT for patient. Is the cast removal, anesthesia, and new cast billable for this provider? This is the first time patient has seen this provider for the fracture.

On this subject of fractures, I would like some clarification on the initial encounter scenario. I have done a lot of research in regards to this but have found conflicting info. If a provider has not seen the patient before but is doing fracture care after the fact someone else has put the initial cast on is this considered an initial visit for the provider? Or is it if the patient has had any care prior, it was considered initial and all visits after are subsequent regardless of the provider seeing the patient for the first time or not?

Resolved vs resolving; I know as a coder we do not code a resolved condition. However, if patient is in for follow up of bronchitis and it is now resolved, do I code for the bronchitis again? That is why the patient is being seen and there are no other diagnoses with the visit.

Out of curiosity; how many providers are billing 99215? I have one who does his own E/M and he is fond of using 99215; too often I feel. But I was taught and what I have read about 99215 is it is a life threatening situation. Some examples of this please? That would be helpful to me and greatly appreciated. I provide E/M for another provider and on the flip side of this, I don't want to be undercutting it either.

In terms of chronic conditions and follow up visits for them: Note reads: Here for follow up ROS is done PE is done both are complete Assessment states only the conditions-some say controlled or at target most do not-sometimes it says things like bronchitis/pneumonia Plan states continue on current meds unchanged
I pull my hair out with this because my coder mind says nothing is clearly stated, conditions are not linked to the meds, and it seems nothing is codeable to me! Only conditions stated at target or controlled. Help with this would be greatly appreciated! And how about the one condition/another condition ??? Yes, I reread the note to see if it is stated elsewhere but what to do with a vs scenario?

I have also found in my short experience that providers do not like to be told how to document, and it is usually their MA's doing it anyways. I keep suggesting that I will be happy to put together info in regards to proper documentation and I have done a few things. But this is met with resistance from most of the providers.

I thank you in advance for info regarding my above questions. I want to code things as correctly and accurately as possible!
 

jdibble

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Wow - this post is overwhelming!!! Let me try and help you with what I can. Hopefully others will be able to help you with what I can't! My answers are in red below.

I am a CPC-A as of December 2015 and am proud and happy to say I have been working since January of 2016. First remotely for a few months and now I am working as a coder for a medical billing company. We bill for 18 different providers of various specialities and I get access to many different types of encounters. I have many questions in regards to what I have learned vs how it really works in the real world!

If a patient comes in for a B12 shot and does not see the physician what are the correct codes? I have been doing 96372 and J3420. Now I was initially coding 99211 with that as I was taught that is a nurse visit but then I read, on here somewhere I believe, not to bill 99211 w/injections. So which is correct?

If the patient is scheduled to come in for a B12 injection and that is the sole purpose of the visit, then you would only bill the injection code and the drug code. You would never bill a 99211 with any procedure codes.

Same scenario as above but patient does see the physician but nothing else is documented but the B12 shot; what are the correct codes for that? The same? Being that a complete office visit is not done or documented; just the B12 shot.

Again, if the patient is scheduled to come in for the shot and that is the purpose of the visit you would only bill the injection code and the drug code. Only if the doctor saw the patient for a separate reason (i.e. patient complains of cough) and documented a full note with all of the required elements, could you bill an E/M code with the 25 modifier applied along with the injection and drug codes.

And on this note, when would you bill 99211? When will a patient come in only to see the nurse and not get an injection? Maybe a blood pressure check?

If the doctor has documented a plan of care for the patient to come in for a BP check (or a wound check, etc.), yes then you could bill a 99211 for the blood pressure check.

This one has me really stumped. A patient who broke his leg up north, had a cast put on up north, now home and wants a 2nd opinion. The provider sees this patient for the first time (weeks after the initial cast was put on; by another provider mind you) and sends him for X-rays and reads them immediately and fracture is healed so this provider removes current cast with anesthesia for cast removal, and applies another cast (not sure if this is a walking boot or what-waiting on more clarification from the office) and orders PT for patient. Is the cast removal, anesthesia, and new cast billable for this provider? This is the first time patient has seen this provider for the fracture.

I would need more information on this - such as the procedure note - to see what was done. Why was the patient's cast removed under anesthesia? If the fracture was healed, why was it re-casted? If the patient had been under the care of a physician in the north, did that physician bill the global fracture care code? This would be an issue for how your physician could code this visit.

On this subject of fractures, I would like some clarification on the initial encounter scenario. I have done a lot of research in regards to this but have found conflicting info. If a provider has not seen the patient before but is doing fracture care after the fact someone else has put the initial cast on is this considered an initial visit for the provider? Or is it if the patient has had any care prior, it was considered initial and all visits after are subsequent regardless of the provider seeing the patient for the first time or not?

Again I would need some more information to answer this - was the cast applied in the ED? Did another physician apply it? Or are you asking about the ICD-10 diagnosis codes? If that is what you are asking then if this is the first time that this doctor is seeing the patient for this fracture than they would use the A in the 7th position.

Resolved vs resolving; I know as a coder we do not code a resolved condition. However, if patient is in for follow up of bronchitis and it is now resolved, do I code for the bronchitis again? That is why the patient is being seen and there are no other diagnoses with the visit.

I would code the bronchitis

Out of curiosity; how many providers are billing 99215? I have one who does his own E/M and he is fond of using 99215; too often I feel. But I was taught and what I have read about 99215 is it is a life threatening situation. Some examples of this please? That would be helpful to me and greatly appreciated. I provide E/M for another provider and on the flip side of this, I don't want to be undercutting it either.

If your provider is coding a high number of 99215 he is opening himself up for an audit. I cannot tell you if he is correct in using these codes because it would all depend on medical necessity - and without seeing each individual note and auditing to make sure that all elements meet the requirements of a 99215 as well as if they are medically necessary, you cannot just assign that code for all patients. You as the code need to be reviewing all of the documentation to make sure he is correct in using this code.

In terms of chronic conditions and follow up visits for them: Note reads: Here for follow up ROS is done PE is done both are complete Assessment states only the conditions-some say controlled or at target most do not-sometimes it says things like bronchitis/pneumonia Plan states continue on current meds unchanged
I pull my hair out with this because my coder mind says nothing is clearly stated, conditions are not linked to the meds, and it seems nothing is codeable to me! Only conditions stated at target or controlled. Help with this would be greatly appreciated! And how about the one condition/another condition ??? Yes, I reread the note to see if it is stated elsewhere but what to do with a vs scenario?

I am a little lost in what you are asking here. However from the first sentence I do not see enough documentation to support a history or an exam. Simply stating that ROS is done does not qualify for a complete (or any documentation for that matter) ROS. And PE is done also does not qualify for any exam, let alone complete. This would be an unbillable visit from what you have here for documentation.

I have also found in my short experience that providers do not like to be told how to document, and it is usually their MA's doing it anyways. I keep suggesting that I will be happy to put together info in regards to proper documentation and I have done a few things. But this is met with resistance from most of the providers.

Finally - you have hit it right on the head! The majority (there are a few - and I mean a few) of providers do not want to be told how to document, nor do they want to hear that what they document drives what level they can code. They say "they are here for patient care" and the do not see the correlation between good documentation and good patient care. I fight with this every day and there is no winning! Just keep trying to educate them, and code the charts according to what has been documented - that is all you can do. One thing of concern in your statement though is that you say the MAs do the documenting??? No, No, NO! They cannot document the chart - only the ROS and the PFSH can be documented by ancillary staff and even then the doctor must document that he has reviewed this information in order for it to counted towards his documentation. The CC, HPI, Exam and Assessment and Plan must all be documented by the physician!

I thank you in advance for info regarding my above questions. I want to code things as correctly and accurately as possible!

I hope some of this has helped. If not, please re-ask your question but I would suggest that you break it down into separate questions - you will get more answers that way! ;)
 

CPCA2016

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Thank you for all your helpful info! Sorry, I don't mean to be overwhelming, I just have a lot of questions! I appreciate you taking the time to help me out!
In regards to the provider with the fracture; I now have that figured out. I was at a class for the new codes and changes for 2017 and got that answered by an orthopedic biller.
In regards to coding chronic conditions the provider does document a complete physical exam as well as complete ROS; I didn't want to type all that out. My questions are based on if it states the name of the condition and not like "controlled" or "at target" is it really assessed? And if it only states "'continue on current meds unchanged" is that considered treatment for the conditions?
And some new questions...if a simple repair is included in say laceration repair-when would those simple repair codes ever be used? I code for urgent cares and they all code intermediate repair but they are all simple repairs; I believe that gets figured into the E/M correct? But when would you ever use those simple repair codes then?
In regards to "bronchitis vs pneumonia " how do you code from that? I don't believe we do but would like input on that. I come across that often. Different conditions but one vs the other with out a definitive diagnosis. Code the signs and symptoms then?
In regards to the provider billing 99215 often; time is documented in most cases as being "more than 35 minutes spent face to face"; however I thought medical decision making is the driving factor for E/M? I mean I know about the risk table and the # of diagnosis and management options etc. Some cases are a refill for birth control or follow up on diabetes and hypertension. I mean just because 35+ minutes are documented if the medical decision making and the rest of the requirements aren't met is it acceptable to use 99215 based on time solely? And that provider does get audited, often. He doesn't care and insists on doing his own E/M coding. It makes me crazy though.
Again, I thank you for all your input! I'm learning a lot and I want to code correctly!
 

CPCA2016

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Forgot to also mention in regards to A D S injury codes-I was told at the 2017 code changes class that if the patient is seeking active treatment for fracture/injury that is healing use the A.
 

jsalzer50

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Coding

Greetings,

Coding is not easy, and (especially as a new coder), it's completely normal to have lots of questions. (I just started working as a coder myself).

One of the main things my trainer drills into my head is to read my references, ALWAYS: ICD-10-CM guidelines, CPT guidelines, Coding Clinic, CPT Assistant----these are tools that are always at-hand for me and I'm developing a habit of referring to these every day. In fact, today, I'm going to read ALL the new ICD-10-CM guidelines for 2017, not to memorize them, but to at least become familiar with them, so I can adjust and know where to look when coding tomorrow.

I overheard some people mentioning that reports documented in 2016 are coded using 2016 guidelines, and so even with the new 2017 ICD-10-CM guidelines and new codes, my understanding is we are NOT using those when coding 2016 records prior to Oct. 1, 2016.

Here is my response:

"In regards to coding chronic conditions the provider does document a complete physical exam as well as complete ROS; I didn't want to type all that out. My questions are based on if it states the name of the condition and not like "controlled" or "at target" is it really assessed? And if it only states "'continue on current meds unchanged" is that considered treatment for the conditions?"

I think a lot of this depends on where it's documented in the report.

We know ROS is subjective info from the patient. If a condition is documented under ROS, I'm going to include that when coding E/M.

We know the PE is objective info from the MD. If a condition is mentioned in the PE, I'm going to include that when coding E/M.

If it states "continue on current meds unchanged" and that is the only treatment/Plan documented, I would mark that as current treatment for the conditions. Please don't take my word for that one though, as I don't code E/M at work....only ICD-10-CM and CPT. I remember coding E/M in school....it's not easy!

"And some new questions...if a simple repair is included in say laceration repair-when would those simple repair codes ever be used? I code for urgent cares and they all code intermediate repair but they are all simple repairs; I believe that gets figured into the E/M correct? But when would you ever use those simple repair codes then?"

I never code CPT repair codes for urgent care at all.

For EDs, I code CPT simple and intermediate repairs, but I code to intermediate repair ONLY if I have sufficient documentation. Just a few notes that say something like "wound is intermediate, extensive irrigation, closed with simple sutures..." is NOT sufficient to code intermediate repair. We would need more documentation. I've been told as a general guideline to code the lowest for repair CPT codes if documentation is not clear or you are stuck between 2 CPT repair codes. Go with the lowest. Also, I strongly encourage you to read/review the definitions of Repair in your CPT code book, as that will help when coding CPT repair codes.

"In regards to "bronchitis vs pneumonia " how do you code from that? I don't believe we do but would like input on that. I come across that often. Different conditions but one vs the other with out a definitive diagnosis. Code the signs and symptoms then? "

Yep, in those cases, I code the signs/symptoms. When I code urgent care, I often come across similar documentation. Because it's "likely pneumonia" or "differential dx is...", or "possibly this" or "consistent with", or "this vs that"........I ONLY code the symptoms. That is the most definitive dx we got. I'm not going to code a differential dx.

"In regards to the provider billing 99215 often; time is documented in most cases as being "more than 35 minutes spent face to face"; however I thought medical decision making is the driving factor for E/M? I mean I know about the risk table and the # of diagnosis and management options etc. Some cases are a refill for birth control or follow up on diabetes and hypertension. I mean just because 35+ minutes are documented if the medical decision making and the rest of the requirements aren't met is it acceptable to use 99215 based on time solely? And that provider does get audited, often. He doesn't care and insists on doing his own E/M coding. It makes me crazy though."

In school, I used an E/M Audit sheet to obtain the History, Exam, and Medical Decision Making, but (even after that), I had to use medical necessity as the driving force for the codes I chose and....... time.

Here is a very important note re: time and E/M coding, see page. 10 in CPT 2016 Professional Edition:

"When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M Services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record." (CPT 2016 Professional Edition, Page. 10)

So.....time IS the driving factor for E/M coding ONLY if counseling/coordination of care consists of more than 50% of the encounter.

E/M coding is challenging. Keep at it.

My very best to you and yours~

Sincerely,

Jacob
 
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CPCA2016

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I thank you for your input.

In my training through AAPC I was taught/told that a simple repair is included in the E/M; hence my question regarding coding it separately.

I do read my books and refer back to them often. They are the driving force behind coding rules and guidelines. However, I am learning in the real world of coding for reimbursement the rules and guidelines do not take precedence. What gets paid does. And insurance companies have the final say if codes are payable or not and they can change their mind instantly on that.

Medicare does not accept M50 or M51; that is an example I recently learned. Even though CPT's instructional states to use it. A claim was rejected because of that.

On the opposite side of that however, I have also learned that almost all claims are rejected based on incorrect insurance info, not incorrect codes.

I believe coding in the "real world" is somewhat different than what we have been taught.

And that is ok I suppose; I still just want to code my work correctly. ??
 
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