Wiki Referrals and MDM - I work for an urgent care


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Good Afternoon,

I work for an urgent care organization and we average roughly 60 referrals per day. I reviewed the CMS 2014 E&M guidelines and under the MDM section for "Number of Diagnoses and/or Management Options":

If referrals are made, consultations requested, or advice sought, the record
should indicate to whom or where the referral or consultation is made or from
whom advice is requested.

I don't see where this actually calculated in the MDM tables. I was looking at the 2016 CPT Code Changes and the prolonged services caught my attention. For example, we had a workers comp patient present a hand injury that required same day surgery. Our nursing staff was tied up over an hour on the phone trying to find a hand surgeon in the area that was willing to take the patient on the same day.

How do we get reimbursed for the time spent working on referrals? Is it part of the MDM and if so, how is it calculated? Can the nursing time spent working on the referrals be billed under the new code 99415 prolonged clinical staff services with physician or other qualified healthcare professional supervision?

Does anyone have insight or information that I can share with my management?

Thanks in advance!

Hi Dana,

The MDM tables are for calculating the physicans work so the nurses work wouldn't be captured there.

Also the nurse would have to be face-to-face with the patient providing care the whole time in order to use the 99415 based on the range guidelines-see below.

Range Specific Guideline

Codes 99415, 99416 are used when a prolonged evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description. The physician or qualified health care professional is present to provide direct supervision of the clinical staff. This service is reported in addition to the designated E/M services and any other services provided at the same session as E/M services.

As far as I know there wouldn't be a way to factor it into the EM code and there wouldn't be a separetly billable service for this either.