Coding for Elderly Patients and Interactive Complexity

Q: My physician wants to bill a 69209 ear lavage and 69210 cerumen disimpaction code together. Is that OK?

A:  No, it's not OK.... the 69210 includes 69209 per CCI edits, and the instructions in CPT for 69210 also tell you not to do that. The only way you could bill these codes together would be if you performed a lavage only on one ear and a manual disimpaction (that could have included some lavage) on the other ear. You'd add an RT and an LT on the appropriate codes to make it clear.

Q:  I'm doing depression screens on elderly patients as applicable, but I'm confused as to whether I should be using a G8510 code or a G0444.  And regarding the screening codes in general (e.g obesity, alcohol misuse, depression), what type of verbiage do I need to put in notes in order to support these? Must they be separate notes from new/established patient notes?

A: Regarding which codes - you can include both on your claim form. You want to use the G0444 to report your professional services in doing the depression screen. The G0444 is a HCPCS code – the Medicare version of the CPT level I code is the payable one. 

The G8510 is a level II CPT code for the [Physician Quality Reporting Initiative]– it is a performance measure and not reimbursed directly - just part of the overall quality measures.

You also want to be sure to document the time you spent doing the screening. The code description calls for 15 minutes although some providers read that as 'up to' 15 minutes (some payers do not).

These don't have to be entirely separate notes, just identified within the overall note as a separate thing. You can include a heading such as, 'Alcohol Misuse Screening' followed by a description of the content, and the time you spent doing it.

Q:  I have a question about coding when it comes to 90785 for interactive complexity.  If I have a patient who is legally competent but wants to bring in his wife and mother to assist with collateral because he's not been doing well, would that be a time to use that code? The visit already took longer because of the discussion with the family members and was of higher complexity due to various other things that came up regarding diagnosis and medications. As such, I already billed it as a 99214 but was wondering if it should have also been a 90785? And when I have patients coming from group homes who are not competent and I have to get history from the staff and from legal guardians present for the visit, would that be a time to use that code (even if it's a basic follow-up visit 99213)?

A: Good question about the interactive complexity code. The short answer is that you can't use it with the 99213 and 99214 E&M codes:

According to the CPT manual, "Add-on code 90785 may be billed along with a diagnostic evaluation (90791), an individual psychotherapy service (90832, 90834 or 90837), or group psychotherapy (90853). In order to use code 90785 at least one of the following factors must exist: 

• Maladaptive communication (for example, high anxiety, high reactivity, repeated questions or disagreement) 

• Emotional or behavioral conditions that inhibit implementing the treatment plan 

• Mandated reporting (for example, in cases of neglect or abuse) 

• Play equipment, devices, interpreter or translator required (see relevant guidance from CMS)"

What you are describing below falls much more under the coverage of prolonged services 99354 - 30 minutes beyond the basic service. Let's say you spend a total of 25 minutes counseling and discussing things with family members - you can write 'spent over half of 25 minutes counselling on x,y and a 99214 is supported.' If you then note that you 'spent an additional 30 minutes (or beyond) in prolonged services,' you now get 99214 and 99354.

The bad news is that you need to have at least 30 minutes beyond the basic code to get the 99354.

If it were a total of 45 minutes, however, you could bill 99213 and 99354. Think about the various uses of time with CPT as opposed to the interactive complexity code.