Coding for a Patient That's Not Present

Q: An internist has an elderly patient and the daughter wants to come in for an office visit without the patient, to go over paperwork for [do not resuscitate] etc. She wants the patient's Medicare billed. Is there a code we can bill for this?

A: Although it has always been a mainstay of Medicare policy that a patient needs to be present in order to meet the definition of an 'encounter' - there are exceptions.

Medicare, for example, departs from the CPT manual definition of counseling and coordination of care, which allows for patient/family and requires that the patient be present.

But some codes by their nature of definition don't require patient presence. Depending on the patient's circumstances, the situation above might be covered by the care plan oversight codes 99340, 99375, 99378 or 99380.

However, if the provider documents at least 16 minutes of time dealing with these end-of-life issues with the daughter - a 99497 Advanced Care Planning code can be billed. The Medlearn article on this on the CMS website specifically states family members. This a relatively newly payable code for Medicare.

Q:  Can you tell me if an anatomic pathology lab can use modifier 79 to get paid for a biopsy technical and professional fee if the biopsy has nothing to do with the global period the patient is in.  For example,  a patient is getting chemotherapy as an outpatient and goes to a dermatologist for a biopsy of a mole.  The dermatologist sends that biopsy to me.  The dermatologist doctor gets paid, but Medicare says the biopsy technical component lab fee is in the global period. 

A: It sounds like someone is mixing up some concepts here. A biopsy code describes the surgical service of obtaining tissue that will then be submitted for pathologic examination. The only global component of the biopsy would perhaps be related to wound care. The correct coding edits (CCI) do not bundle the surgical pathology codes into the biopsy codes.

That aside, even if the dermatologist that did the biopsy was in a global period (and the generic biopsy codes have no global), the pathologist would not be in the global.

By mentioning chemotherapy, there is some inference that there may have been some previous excision or resection of a tumor, polyp or lesion. In that case, if there is some confusion about this specimen being related to a previous specimen -a 59 modifier is technically preferable, although that is usually used to distinguish between multiple procedures on the same day. Modifier 79 is not listed for the surgical pathology codes.

Q:  We need the procedure code for instilling fluorescein into the eye to check for corneal abrasions with the Wood's lamp.

A: The fluorescein stain application alone is not a billable code. The billable version of this is a corneal foreign body removal with or without the lamp.

In many cases the application and exam is billed as part of an E&M visit. The code 92230 was changed some years ago and can no longer be billed for this service.

If you do remove a corneal foreign body as a result of this, you would bill either 65220 or 65222 for the without or with lamp respectively. Theoretically you could bill either of these two codes without actually removing  a foreign body, and append a modifier -52 for reduced services - but this would quite likely not be paid in would certainly require that documentation be sent with the claim.