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Please help! Second time posting this question...

  1. #1
    Exclamation Please help! Second time posting this question...
    Medical Coding Books
    I could really use some feedback on this situation:
    One of the doctors that I work for saw a patient's family to discuss the pt's new diagnosis of MS. On the same day, the patient was having an infusion done in the office, but was not in the room. The doctor states he spent an hour discussing the pt's diagnosis with the family, and wants to know if this is billable. (FYI: Pt's insurance is Anthem, PHP)
    Here's what I'm thinking, and please someone let me know if I'm correct: We can bill the established office visit code 99215 because it states "patient and/or family" and more than 50% of the time spent was regarding counseling/coordination of care. I would also put a modifier 25 on it because I'm billing out the infusion on the same day.
    There wouldn't be any use of the "prolonged service codes", correct? Because the time would only be 20 minutes longer than the amount of time listed for the 99215 code.

    Thanks for anyone's reply!

  2. #2
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    That sounds correct to me...

  3. Default
    that is exactly what I would do-

  4. #4
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    You stated the patient was in the office for an infusion. Did the physician examine the patient the same day he discussed the new diagnosis with the family. If he did not meet the criteria for an E & M level (Hx, exam, MDM) you can not bill out an E & M code

  5. #5
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    Quote Originally Posted by anne1607 View Post
    You stated the patient was in the office for an infusion. Did the physician examine the patient the same day he discussed the new diagnosis with the family. If he did not meet the criteria for an E & M level (Hx, exam, MDM) you can not bill out an E & M code
    I respectfully disagree. "When more than 50% of the encounter is taken up by counseling (in this case, it's 100%), then TIME becomes the key or controlling factor to qualify for a particular level of service". That quote is straight from the CPT book.

  6. #6
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    Yes, that is what I was thinking... thanks so much for your help!

  7. #7
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    I do not agree with that. I believe the patient would still need to be there face-to-face with the physician. If you look under the Definitions of Commonly Used Terms it states under new and establisht patient - profesional services are those face-to-face services. What if it was a patient that had never been seen and the family comes in to talk about a diagnosis with the dr before he see's the patient for the first time. Would you bill a New patient since the family was counselled for that?
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  8. #8
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    Quote Originally Posted by Herbie Loroña View Post
    I do not agree with that. I believe the patient would still need to be there face-to-face with the physician. If you look under the Definitions of Commonly Used Terms it states under new and establisht patient - profesional services are those face-to-face services.
    I was addressing the OP in which the patient was already established. Meeting with the family IS a face-to-face service.

    99212-99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components.
    -detailed history
    -detailed exam
    - MDM of moderate complexity

    Physicians typically spend XX minutes face-to-face with the patient AND/OR THE PATIENT"S FAMILY.

    When counseling dominates the physician/patient AND/OR FAMILY ENCOUNTER, then TIME may be considered the key to qualify for a particular level of service.

    I stand by my comment.
    Last edited by Walker22; 12-23-2009 at 08:13 AM.

  9. #9
    Default
    Quote Originally Posted by Herbie Loroña View Post
    What if it was a patient that had never been seen and the family comes in to talk about a diagnosis with the dr before he see's the patient for the first time. Would you bill a New patient since the family was counselled for that?
    How can a doctor talk about a diagnosis with the family if he/she has never seen the patient? How can there even BE a diagnosis?

  10. #10
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    Here is what I got from the CMS website.

    C - Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling
    Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

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