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coding when patient not present

  1. #1
    Default coding when patient not present
    Medical Coding Books
    We had a mom in for an appointment today with out her child. She wanted to discuss some issues the child is having. Can we bill this as an office visit based on time?
    Thanks.

  2. #2
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    Quote Originally Posted by lstuder View Post
    We had a mom in for an appointment today with out her child. She wanted to discuss some issues the child is having. Can we bill this as an office visit based on time?
    Thanks.
    This is somewhat debatable...there are different interpretations of the guidelines, because of the gray areas in them - some people will tell you yes, as long as the total amount of time spent in counseling/coordination of care is documented, and it exceeds 50% of the encounter. The face-to-face requirement is met, because the patient's mother is having the discussion face-to-face with the provider.

    I'm not one of those people, though...
    In my opinion, without a physical exam documented, you wouldn't be able to report a problem-oriented outpatient E/M. My view on it is, that the key components (History/Exam/MDM) are required to be documented, in order for the service to meet the CPT definition of the E/M, even though they're not always taken into consideration for the purposes of selecting specific E/M level. I have a really drawn-out analogy involving a peanut butter and jelly sandwich that I like to use - I won't go too much into detail right now, but in a nutshell:

    Components of problem-oriented E/M's are much like the ingredients needed to make a PB&J sandwich...
    History is like the bread: it's the foundation of the visit, which everything else is built on.
    The exam is like the Peanut butter: it's the substance of the visit
    The jelly's the MDM, (mostly because it's done last, really...)
    The other element that's required for an E/M, but not considered a 'key component', is medical necessity. It's the knife in the analogy - you need it to make the sandwich, but it's not technically an ingredient.
    You only have a PB&J sandwich if you have all of the ingredients - otherwise it's just a peanut butter sandwich, or jelly sandwich, or peanut butter & jelly pile of goo...But I digress...the point is, without all of the key components, you don't have a problem-oriented E/M, even when Counseling/CoC dominates the visit. You may have most of it, but it's technically not a 'peanut butter and jelly sandwich', without the PB, jelly, and bread.

    The guidelines say that when counseling/CoC dominate the encounter, they become the key or controlling factor in determining the level of E/M - it doesn't say that it replaces the components, or negates the need to have them, but just that it becomes the most significant factor, when deciding which code to use.

    The biggest point of contention, (and the one that others will disagree with me most on), is whether or not all 3 key components are required for established patients - it would make all of the difference in this situation. Some people read the guidelines as: only 2/3 key components are required, period. As you can see with my previous PB&J analogy, I don't tend to agree with that; I still think that all of the ingredients have to be there to make the problem-oriented E/M a problem-oriented E/M, but that the overall E/M's level is just based on the best 2 out of 3 levels of each component. But, that's just my interpretation, and it's not supported any more than the other viewpoint, by anything in the text of the guidelines.

    There are E/M codes that describe your encounter, though - just not the regular outpatient 99201-99215 codes...try looking into 99401-99404,and look around near the Care Plan Oversight codes for the codes that describe face-to-face & non-face-to-face physician services that don't require an exam in their description (I'm not sure that the codes I'm thinkg of are the CPO codes, but I know that they're at least near them...sorry - I don't have my book at home right now). Good luck, and if you haven't found your answer by tomorrow, I'll see if I can give you a more specific idea of a place to look...Hope that helps!
    Last edited by btadlock1; 10-13-2011 at 10:15 AM.

  3. #3
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    You might want to take a look at the CPT 96155 grouping.... Also, if you choose not to use the usual E&M CPT, 99499 is always an option. Just be ready to submit supportive documentation. You might be required to battle for providing your services!

  4. #4
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    Quote Originally Posted by hewitt View Post
    You might want to take a look at the CPT 96155 grouping.... Also, if you choose not to use the usual E&M CPT, 99499 is always an option. Just be ready to submit supportive documentation. You might be required to battle for providing your services!
    The codes I was thinking of were Medical Team Conference codes - they won't work, so disregard that. 96155 would probably work if they were discussing a problem, but if it was for preventive-type stuff, see 99401-99404.

  5. #5
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    Thanks!

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