'Bundled' Denials; Reimbursing Calls; Same-day Visits

Time-based Codes

The January 2012 issue of Physicians Practice included some inaccurate guidance for updated regulations regarding time-based coding. We have corrected the error on PhysiciansPractice.com and we reprint the question, with the corrected answer, below.

Q: I hear there is a major change in the way time is counted in terms of counseling and coordination of care, but I can't find it in the CPT manual?

A: I wouldn't refer to it as a "major change," but there was some new explanatory text in the CPT 2011 Professional Edition, Page XII, that covers time-based codes.

The placement of the guidance is a little odd because there is already a section of the E&M guidelines that details time-based codes. That the new text comes in the introduction indicates that the explanation applies to all time-based codes - regardless of where they appear in the rest of the manual.

In the new text, one sentence in particular may have considerable impact on primary care when applied to E&M codes in certain circumstances. The sentence reads: "When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used." (Emphasis mine.)

The two areas of the CPT manual which meet these criteria (that include significant numbers of codes ranked in sequential times) are the E&M codes section and the psychotherapy codes section. The E&M code descriptions - at least for the standard office, inpatient, and consult codes - use the term "typical times." The psychotherapy codes do not.

To qualify for coding by time, more than half of the visit has to have been spent on counseling or coordination of care. Nothing has changed in that regard. When selecting a specific code, the assumption until now has been that the total encounter time needs to at least meet the typical time identified in the code. For example, the typical time for a 99215 is 40 minutes - so to bill a 99215 based on time, the visit would have to have lasted at least 40 minutes, with at least 21 minutes spent on counseling or care coordination.

Under the new language, you select the specific code based on which "typical time" the actual visit was closest to. This suggests that if the actual time of a visit is, say, 35 minutes, and you spent more than half of this time counseling, then the correct code is 99215, because the 35 minutes is closer to the typical time of 40 minutes (99215) than the typical time of 25 minutes (99214).

Another example could involve a 99214. The typical time for a 99214 is 25 minutes. So based on the new text, if the actual time is 22 minutes, and the counseling by time criteria is met for that (at least 12 minutes in this case), then you have a 99214 based on counseling with a 22-minute total visit.

It sounds like we're splitting hairs here, and most providers don't keep precise track of time for coding purposes. But it is meaningful. While a 35-minute visit versus 40-minute visit may not happen a lot, but those 5 minutes add up.

So, if you code based on exactly what it says in CPT, then that is exactly what it says to do. Make sure that you are comfortable with the interpretation of these text changes before you change your coding behavior.

In 2012, the definitions of prolonged services have also relaxed somewhat. The words "face-to-face" contact have been changed to "direct contact and the word physician has been dropped from the description. So there is a loosening of terms here as well. But make sure you understand the distinctions.

Billing Labs

Q: Typically, we code for labs and send the claims before the lab results finalize. I've heard of other clinics waiting for the lab results to finalize, as the results could impact the diagnosis codes on the claim. This got me thinking - some lab results require additional time and follow-up from the doctor - so if we were to wait on the lab results and follow-up with the patient, could this extra work be accounted for in the E&M code?

A: You really have two questions here. One is a CPT coding question and the other is an ICD-9 question. But they are somewhat intermingled.

On the CPT side, the physician gets credit for the "order/review" of labs during the initial visit. Any additional work, time, and follow-up related to the labs would have to be face-to-face, (in the outpatient setting), and thus require another visit for billing purposes, as the non-face-to-face time couldn't count toward the initial encounter.

Whether a given condition is coded on the diagnosis coding side does depend on whether you have diagnosed that condition at the time the encounter is billed. If you bill the encounter with the signs and symptoms because the condition you are looking for has not been ruled in, you conceivably could get a denial based on the medical necessity of the lab, but this doesn't happen very often.

If you wait until any and all potential diagnosis codes are in from the lab, you would likely avoid potential medical necessity denials because now a condition may be ruled in and thus is reportable. But this really wouldn't change the CPT code - just the diagnosis codes.

So, I'd just leave it alone and make sure your CPT levels are as correct as they can be in the first place. If you want to wait on labs for diagnosis purposes that's fine, if perhaps unwieldy, but I'd only bother if you have a denial problem.

'Bundled' Denials

Q: I always use modifier 57 when deciding to perform surgery on the same day, however, payers never pay, stating it is still bundled.

A: Watch out for "always" and "never" - often a problem with coding. Do the denials just state "bundled" with no detail? What is the surgery? We'd need a bit more information here to really make any sense of it, thanks. But generally what you are describing is appropriate if the procedure has a 90-day global surgical period.

Reimbursing Calls

Q: I make a lot of phone calls to manage patients, such as addressing side effects of medicines, a child exhibiting bad behavior requiring the adjustment of medicine, etc. These phone calls take a lot of time, which is currently not billed. I document these calls. I wonder whether there is a CPT code that I can use to charge the calls.

A: Thanks for asking - but the bad news is that although there is a CPT code that represents phone calls, it is almost universally not reimbursed. The coordination-of-care time in the outpatient setting must be face-to-face.

I wish we could help you with this one; a lot of physician work goes uncompensated and unrecognized here. All the better reason not to undercode your visit services!

ER Codes and Preferential Treatment

Q: I am an internist not affiliated with a hospital. When I see a patient in the emergency department, I typically use the 99281-99285 series of codes. I am told by the hospital that I can't use these codes - that they are just for ER physicians. Is this true?

A: Per the AMA, if a patient is evaluated by an ER physician prior to an evaluation in the ED by another provider type, then the ER physician has preferential treatment in the use of the ER codes (99281-99285).

Other providers seeing/treating the patient in the ED following your work have access to 99201-99215, 99218-99235 (as appropriate), and 99241-99244. The ER provider really has only the one range of codes. What is more interesting about this question lately is that since Medicare stopped paying for the consult codes, providers such as yourself who may be asked to render an opinion in the ED are then forced to use the 99201-99215 series if they did not admit the patient. This is what Medicare tells you to do. But these codes have lower RVUs than the consult or ER codes - and you lose revenue as a result.

This may explain why there is an increase in the use of the ER codes by non-ER physicians, and why ER providers are feeling it when other providers use these codes.

Reimbursing Two Same-day Visits

Q: When an OB sees a patient in his office then later sees the patient again in the labor and delivery area of the hospital, how does he account for both visits on the same day?

A: Good question. I guess you've found out that two outpatient office-visit codes on the same day don't get reimbursed. One way to navigate this would be to combine the work in terms of history, exam, and decision making, or time involved in the office visit, and add it to the work involved in the L&D setting.

If the patient is "admitted to OBs" in the L&D area, the combined services could be billed under the 99218-99220 or 99234-99236 codes depending on the outcome and whether or not the patient goes home that same day.

If there is no such order, then either an outpatient visit code representing the combined work or an outpatient code with a prolonged services code could be billed. Don't forget that the place of service codes change from the office to outpatient hospital in the above scenarios.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the March 2012 issue of Physicians Practice.