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Thread: e/m for test results

  1. #1

    Default e/m for test results

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    If a patient comes in for STD testing results which are negative, Can you charge an E/M? That is the only reason why the patient came in. The doctor does state that Safe sex, abstain from IVDU were discussed in detail. Should I code a 99401 with V64.45 and
    V64.44? Please help I am VERY new to primary care. Thank you

  2. #2
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    Default Reference

    http://www.cms.gov/manuals/downloads/clm104c16.pdf

    Section 30.4 discusses payment for physician review of lab results. If the only service is to report lab results, then it appears billng for this on a return visit is not appropriate. If additional sevices are provided and documented, services which meet the threshold of medcal necessity then additional billing might be appropriate.

    The only other consideration that comes to mind is the duration, and necessity of the counseling, i.e. If the counseling lasted for more than 50% of the visit, which would have to be in the documentation. If this is the case, you may code for the appropriate level of office visit based on time. See time based e/m coding under behavioural health

    Hope this helps
    Last edited by jackson7591; 07-21-2011 at 08:55 PM.

  3. #3
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    Default

    Quote Originally Posted by jackson7591 View Post
    http://www.cms.gov/manuals/downloads/clm104c16.pdf

    Section 30.4 discusses payment for physician review of lab results. If the only service is to report lab results, then it appears billng for this on a return visit is not appropriate. If additional sevices are provided and documented, services which meet the threshold of medcal necessity then additional billing might be appropriate.

    The only other consideration that comes to mind is the duration, and necessity of the counseling, i.e. If the counseling lasted for more than 50% of the visit, which would have to be in the documentation. If this is the case, you may code for the appropriate level of office visit based on time. See time based e/m coding under behavioural health

    Hope this helps
    I agree, but there is another code, that I think may work - I don't have my CPT book on me, but I want to say 99401-99404, maybe? They're specifically for counseling/risk factor reduction, but not full preventive exam encounters...worth looking into, but I'm not 100% sure if they'll work, so read the guidelines carefully...Hope that helps!

  4. #4
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    Default Ah - here it is!

    "CPT codes 99401–99409 report counseling risk factor reduction and behavioral change intervention services provided at an encounter separate from the preventive medicine examination. Individual preventive medicine counseling codes 99401–99404 are used to report counseling services in areas such as family problems, diet, and exercise.

    New 2008 CPT codes 99406–99409 for individual behavioral change are available to report intervention services for patients with a behavior typically regarded as an illness, such as smoking or obesity. Group counseling and other preventive medicine services are reported with codes 99411–99429."
    http://library.ahima.org/xpedio/grou...me=bok1_036868

  5. #5
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    Default Agreed

    We have been trying to use these codes more frequently as of late. But also have been trying to educate our providers n proper documentation to support these counseling codes. One particular issue, since we have emr, is that the counseling points are nearly identcal across multiple visits. So we have been asking them to document more clearly their thought processes and medical decision making and how their treatment plan is affected by lab results and conveying this information to the patent.

    And you always have the "oh, i also wanted to ask you about....." patients who provide opportunity to provide services which meet modiier 25 requirements.

  6. #6

    Question Billing 99401 for HNPCC testing recommendation

    Patient came in stating reason for visit "consultation reagrding genetic testing" she has a strong family history of colorectal cancer. The MD is scheduling a screening colonoscopy which under normal cicumstances not allow us to bill an E/M per AGA guidance. However, he did spend 20 minutes counseling her on having genetic testing for lynch syndrome (HNPCC). Would this discussion be billable under 99401 if documented accurately? I am thiking no since the code specifies risk factor reduction which you cannot do for genetics. Help, having self doubts.....

    If no, could we have the pateint sign an ABN stating time with teh physician to discuss this is a non-covered service and bill her directly? I hate to give 20 min of MD time away when the pateint just wants to pick his brain.

    Anna Barnes, CPC, CEMC

  7. #7
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    Default

    Quote Originally Posted by acbarnes View Post
    Patient came in stating reason for visit "consultation reagrding genetic testing" she has a strong family history of colorectal cancer. The MD is scheduling a screening colonoscopy which under normal cicumstances not allow us to bill an E/M per AGA guidance. However, he did spend 20 minutes counseling her on having genetic testing for lynch syndrome (HNPCC). Would this discussion be billable under 99401 if documented accurately? I am thiking no since the code specifies risk factor reduction which you cannot do for genetics. Help, having self doubts.....

    If no, could we have the pateint sign an ABN stating time with teh physician to discuss this is a non-covered service and bill her directly? I hate to give 20 min of MD time away when the pateint just wants to pick his brain.

    Anna Barnes, CPC, CEMC
    I'm not familiar with the rule you're referencing - you wouldn't be allowed to be reimbursed for an E/M prior to a screening colonoscopy, simply because the decision was made to do the screening at that encounter? I could understand not being reimbursed for an E/M the day of the screening (or the pre-op exam at a prior visit), but the visit wasn't entirely routine. Is he the one doing the colonoscopy? If I'm not mistaken, he had to take her history, evaluate her, and then make a decision to perform a screening based on identified risk factors (it seems as though the decision for surgery visit should be covered). If she's a Medicare patient (which I assume she is, by the fact that you mentioned an ABN), then you'd have to meet certain criteria to satisfy the requirements to report an AWV code, but if her insurer is a commercial payer, then in my opinion, you should have sufficient justification to report an E/M in this situation.

    Did she have any complaints (signs/symptoms) to accompany her concern, or was she just worried because of her family history? Did he perform a physical exam, or was the visit predominately based on gathering history and counseling? If she reported signs/symptoms and he performed even a basic PE, then you may be able to report a problem-oriented E/M and select a level based on time, although it's hard to say without seeing the documentation.
    Absent any complaints or exam, I'd say that the counseling you're describing would certainly fit the definition of 99401-99404, but I wouldn't limit the code selection to the amount of time spent discussing the HNPCC, only - deciding to perform a screening colonoscopy sounds like only a small portion of the visit. All of the time that the physician spent in evaluating/counseling the patient on her history and identified risk factors for genetic/cancer problems should be taken into consideration; he did the work, he should get paid for it.
    As for whether or not an ABN is appropriate, my best advice is to contact the payer and ask them directly if the service you intend to report is covered. The problem that you may run into, is that an ABN is intended for use prior to rendering services - meaning that you have to warn them that the visit might not be covered before they receive the service, so that they can decide whether or not to proceed. You can't do the service, then inform them that it might not be paid, and expect them to accept responsibility for it after the fact - it defeats the purpose of using an ABN in the first place. If this is a Medicare patient and the service you decide to report is not payable, then I'm afraid you'll be forced to write off the charge.
    If the patient's not a Medicare beneficiary, then you've got nothing to worry about - just submit the claim for the services rendered, and if it denies, then you should be able to bill the patient. ABN's don't apply outside of Medicare, so whether or not you got one is a moot point for commercial payers. Hope that helps!

  8. #8

    Default

    Thank you for replying. The documentation is specifically focused on genetic testsing counseling for HNPCC with no additional signs and symptoms. the patient came in specifically to talk about genetic testing based on her personal and family history. There was no physical exam.

    If you look at the last parenthicital note under CPT code 96040 it states,

    "For genetic counseling and/or risk factor reduction intevention provided by a physician to patient(s) without symptoms or established disease, see 99401 -99412"

    Codes 99401 -99412 are based on counseling time. I spoke with a coder with the American College of Surgeons who agreed with 99401 based on the documentation.

    If our physcian did discuss other risk factors, signs, symptoms, or diseases along with the genetic testing then I would bill using time as a factor using 99201-99205, 99212-99215, or 99241-99215 if over 50 % of the total time was based on counseling.

    Anna Barnes, CPC, CEMC

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