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Dip UA and 99211?

  1. #11
    Location
    Evansville Indiana
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    451
    Default incident to
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    Most payors follow "incident to" guidelines, however some do not. You would have to check with the individual payor to determine whether they follow the guidelines. The article you refered to is probably not addressing "incident to" but just addressing the CPT guidelines for the billing of 99211.
    So... according to CPT guidelines it would be appropriate to bill a 99211 however depending on the payor it may not be appropriate because it does not follow the "incident to" guidelines. You can access the "incident to" guidelines on the CMS website.

  2. #12
    Location
    Overland Park, KS
    Posts
    1,166
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    Here is what the article says:

    An established patient comes to the office with complaints of urinary burning and frequency. The nurse takes a focused history, reviews the medical record, discusses the situation with the physician and orders a urinalysis. The nurse then presents the findings to the physician, who writes a prescription for an antibiotic. The nurse communicates the instructions to the patient and documents the encounter in the medical record. In this example, 99211 and the appropriate laboratory code for the urinalysis should be reported because the E/M service is distinct from the lab service and appropriate for the evaluation of the patient’s complaint.

    I would agree that 99211 would be appropriate here. There is physician interaction. The physician ordered the UA, reviewed the results, and ordered an antibiotic. The RN is carrying out the provider's order here, so 99211 can be used here. The physician is also onsite and the RN is carrying out the plan of care here, so aren't you meeeting the incident to requirements? I believe so.
    Last edited by dballard2004; 02-12-2010 at 09:45 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  3. #13
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    I believe this is one of those gray areas in a coder's black and white world. My understanding of the first post was the Dr. did not see the patient, did not order the UA, did not discuss anything until after the fact, then gave a script based on results from the nurse. This then would not meet the requirements for incident to. If the Dr. was in fact the one to order the UA, discuss it with the nurse, then prescribe, I agree it could be billed as incident to. There's a difference, subtle, but different in the scenarios listed.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  4. #14
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    I think cheermom hit the nail on the head. Depends on the carrier. The original question was in regards to a medicare patient (Trailblazer). This scenario does not meet CMS requirements for incident to.

    The article posted is more in regards to what supports a 99211, not incident to guidelines.

    Laura, CPC, CPMA, CEMC

  5. #15
    Location
    Pottstown/Philadelphia
    Posts
    266
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    Thanks to everyone. This is huge because the office wants to bill all ua's at this level. I would think the office should take a stand to follow cms guidelines or not to and if we get paid then great and if not, okay too.

  6. #16
    Location
    Columbia, MO
    Posts
    12,560
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    Well geeze! I wish these organizations would not release these types of articles without having them proofed by an authority first. But the article is INCORRECT, and there is is no nice way to say that. If your physician would like I would be more than happy to write a rebuttal to this and send to the organization just give me the address to where I need to send it.

    Debra A. Mitchell, MSPH, CPC-H

  7. #17
    Location
    Overland Park, KS
    Posts
    1,166
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    Would someone please explain to me how this article is incorrect? Based on what I read, the scenario meets the criteria for 99211. What am I missing here?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  8. #18
    Default
    It looks like that article was published in 2004 and sites things from 2000.

    I agree with Debra, this article is incorrect in saying Medicare will pay for these services as 2 of the 4 are new problems and don't meet incident to requirements. It tells you the type of services that can support a 99211 but it is also saying that Medicare will pay for these. She clearly contradicts herself in the article.

    "Medicare's requirements on this point are slightly different: While the physician's presence is not required at each 99211 service involving a Medicare patient, the physician must have initiated the service as part of a continuing plan of care in which he or she will be an ongoing participant. "

    Then goes on to give examples of new problems, like the one previously posted.

    That is why this service does not meet incident to guidelines, the physician did not see the patient for it first therefore they are not following the physicians treatment plan.

    Laura, CPC, CPMA, CEMC

  9. #19
    Location
    Overland Park, KS
    Posts
    1,166
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    So if a patient comes into the clinic with an order from an outside provider (not our doc) for a BP check, this is not a 99211 because our provider did not see them first, or does this only apply to Medicare?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  10. #20
    Location
    Pottstown/Philadelphia
    Posts
    266
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    It is my understanding that this is Medicare specific and not CPT specific. I have found in this journey though that it is payor specific! I am encouraging this family practice to stick to Medicare guidelines. In saying that, I believe that if you are going to follow Medicare guidelines and you do a BP check, your note would have to reference the physician that first saw the patient for that particular problem and a date has to be referenced as well. Not sure if it matters if the provider is from another practice or not. Sorry. Not to mention for our family practice....this means a copay for the patients. I am not so sure I would pay a copay for a UA or a BP check. Doesn't seem right. Someone can correct me if I am wrong, this whole situation just fries my brain!!!

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