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Thread: E/M doc with CT Quesion

  1. #1
    Join Date
    Apr 2007
    Location
    Des Moines
    Posts
    313

    Default E/M doc with CT Quesion

    When our physicians are doing their own CT's and X-Rays, they are waiting to bill them out until the patient comes back in for a follow up visit. At that visit, they will put their 'written report or interp' into the E/M documentation. I feel like they overlap the reason for the visit (HPI, ROS, PFSH...) I just feel like they are wanting to bill out higher levels of E/M visits that aren't justified... This example below is how they look and this particular provider wanted to bill out 99213 and 70486. I think 99213 is too high and as for 70486, the original date it was done was Feb. 1 and the follow up was Feb. 11. I would have billed 70486-TC on Feb. 1 and 70486-26 on Feb. 11th... Am I wrong? I really feel like it would be most appropriate to do a separate CT report showing the actual date of the CT, a reason, The actual CT name (CT with or without contrast and location), then the report and their impression/conclusion. Any one else see a problem with this??? Or am I over-reacting?


    History of Present Illness


    CT Review He presents to discuss sinus CT imaging from last week. He has had a long-standing history of chronic sinusitis and has had a recent acute flare up requiring 2 rounds of antibiotics. He is feeling better now. He has had a trial of chemical cautery in the past without relief. Updated CT imaging was recommended to be compared from May of 2010. He denies nasal drainage or facial pain. He does have a history of trigeminal neuralgia involving the left V1.


    Current Medication
    omeprazole
    montelukast
    carvedilol
    quinapril
    furosemide
    loratadine
    potassium chloride

    Allergy
    lovastatin causes all statins, Statins .

    Review of Systems
    Constitutional Symptoms: Allergies reviewed. Denies fever.
    HEENT: Denies bleeding nose, nasal congestion or nasal discharge.

    Vitals
    Weight:249.20 lbs. Height:77.00 inches. BMI: 30. Temperature temporal: 97.40 F

    Physical Examination
    General Appearance:
    Patient is well-dressed and groomed and appears well in no acute distress, breathing easily.



    ENT
    CT - Sinus Procedure: Pella sinus CT images from 1 February were reviewed personally and were discussed with the patient. Axial and coronal images were available for review as well as those images from May of 2010. The septum appeared fairly straight. There was inferior turbinate hypertrophy which was mild to moderate. The middle turbinates were normally developed. There was moderate mucosal thickening the lining the left maxillary sinus with obstruction of the left osteomeatal complex area. There was opacification of debris in the midportion of the left maxillary sinus. There was progressive mucosal thickening compared to 2010 imaging in the left maxillary sinus. The right maxillary ostiomeatal complex areas patent. There was some patchy mucosal thickening in the left anterior ethmoid cells. No air-fluid levels were seen. There was scant mucosal thickening in the floor of both sphenoid sinuses. The frontal sinuses were patent.


    Assessment and Plan
    ICD: Other Chronic Sinusitis (473.8)
    ICD: Turbinate Hypertrophy (478.0)


    We reviewed his imaging together. I demonstrated the progressive changes in the left maxillary sinus. I pointed out the opacified elements which could represent fungal debris or chronic staph infection. I advised him to consider an endoscopic left maxillary antrostomy with removal of tissue in the sinus as well as left anterior ethmoidectomy. We could also consider radiofrequency inferior turbinoplasties at the same time. I discussed the procedures and reviewed a handout with him. We discussed the risks. At this time he would like to consider our discussions as he is not sure if he would like to proceed with surgery. He will need a preoperative clearance for surgery. We will need to consider this past medical history to determine if he is a candidate for a surgery center procedure.


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  2. #2
    Join Date
    Apr 2007
    Location
    Richmond Virginia
    Posts
    486

    Default

    This is a great question and can not wait to see some responses....but,
    In my opinion you can not bill the 7XXXX-26 after you have billed it the first time. If you are billing your CT's globally they need to be billed with the correct date of service. You can not change the DOS just to please the documentation in the E/M.
    Are you looking at this from the Data points section of the MDM?

  3. #3
    Join Date
    Apr 2007
    Location
    Richmond Virginia
    Posts
    486

    Default

    Quote Originally Posted by BABS37 View Post
    When our physicians are doing their own CT's and X-Rays, they are waiting to bill them out until the patient comes back in for a follow up visit. At that visit, they will put their 'written report or interp' into the E/M documentation. I feel like they overlap the reason for the visit (HPI, ROS, PFSH...) I just feel like they are wanting to bill out higher levels of E/M visits that aren't justified... This example below is how they look and this particular provider wanted to bill out 99213 and 70486. I think 99213 is too high and as for 70486, the original date it was done was Feb. 1 and the follow up was Feb. 11. I would have billed 70486-TC on Feb. 1 and 70486-26 on Feb. 11th... Am I wrong? I really feel like it would be most appropriate to do a separate CT report showing the actual date of the CT, a reason, The actual CT name (CT with or without contrast and location), then the report and their impression/conclusion. Any one else see a problem with this??? Or am I over-reacting?


    History of Present Illness


    CT Review He presents to discuss sinus CT imaging from last week. He has had a long-standing history of chronic sinusitis and has had a recent acute flare up requiring 2 rounds of antibiotics. He is feeling better now. He has had a trial of chemical cautery in the past without relief. Updated CT imaging was recommended to be compared from May of 2010. He denies nasal drainage or facial pain. He does have a history of trigeminal neuralgia involving the left V1.


    Current Medication
    omeprazole
    montelukast
    carvedilol
    quinapril
    furosemide
    loratadine
    potassium chloride

    Allergy
    lovastatin causes all statins, Statins .

    Review of Systems
    Constitutional Symptoms: Allergies reviewed. Denies fever.
    HEENT: Denies bleeding nose, nasal congestion or nasal discharge.

    Vitals
    Weight:249.20 lbs. Height:77.00 inches. BMI: 30. Temperature temporal: 97.40 F

    Physical Examination
    General Appearance:
    Patient is well-dressed and groomed and appears well in no acute distress, breathing easily.



    ENT
    CT - Sinus Procedure: Pella sinus CT images from 1 February were reviewed personally and were discussed with the patient. Axial and coronal images were available for review as well as those images from May of 2010. The septum appeared fairly straight. There was inferior turbinate hypertrophy which was mild to moderate. The middle turbinates were normally developed. There was moderate mucosal thickening the lining the left maxillary sinus with obstruction of the left osteomeatal complex area. There was opacification of debris in the midportion of the left maxillary sinus. There was progressive mucosal thickening compared to 2010 imaging in the left maxillary sinus. The right maxillary ostiomeatal complex areas patent. There was some patchy mucosal thickening in the left anterior ethmoid cells. No air-fluid levels were seen. There was scant mucosal thickening in the floor of both sphenoid sinuses. The frontal sinuses were patent.


    Assessment and Plan
    ICD: Other Chronic Sinusitis (473.8)
    ICD: Turbinate Hypertrophy (478.0)


    We reviewed his imaging together. I demonstrated the progressive changes in the left maxillary sinus. I pointed out the opacified elements which could represent fungal debris or chronic staph infection. I advised him to consider an endoscopic left maxillary antrostomy with removal of tissue in the sinus as well as left anterior ethmoidectomy. We could also consider radiofrequency inferior turbinoplasties at the same time. I discussed the procedures and reviewed a handout with him. We discussed the risks. At this time he would like to consider our discussions as he is not sure if he would like to proceed with surgery. He will need a preoperative clearance for surgery. We will need to consider this past medical history to determine if he is a candidate for a surgery center procedure.
    Let me retract my last statement after reading your question again.... so the pt is coming back to go over the results of hte CT with the Doctor?
    Yes there is a billable E/M code there but what you are saying is he is billing the interp the day the follow up is being done?
    Sorry if I confused this more...LOL

  4. #4
    Join Date
    Apr 2007
    Location
    Des Moines
    Posts
    313

    Default

    Sorry AlwaysSunny! I just saw your comments on this. Yea, I was disagreeing with the physicians on this one... and any others that were similar. What had happened was an E/M was billed out along with a CT- The CT was also billed out on the date it was originally done. I said they had to split it and bill the tc/26 on the appropriate dates. But then I said if they were just going over the results of the CT with those patients, then that was included with the E/M and that they can't bill for another CT interp since the first CT charge was billed out globally. Anyhow, this particular situation was either a clerical error or system error, depending on who/how the charges got entered.


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  5. #5
    Join Date
    Apr 2007
    Location
    Columbia, MO
    Posts
    11,902

    Default

    In order to bill the CT global, there must be a separately documented CT interpretation report. If your provider provides this then fine you can bill global if he send it out then he may bill the TC if you own the equipment, If you own the equipment and no separate interp is provided you may bill only the TC. If there is an official interp provided then you may bill going over the results as part of the MDM.

    Debra A. Mitchell, MSPH, CPC-H

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