Coding Q&A: Combining or mixing service types; HCC code capture

Q1. Patient is seen by a midlevel in an Endocrinology practice and the patient is a ‘hot mess’. She sees the patient and evaluates them and then sends her MA into the exam room to go over how to use insulin or whatever. This ends up taking the MA 30-40 minutes. I know we cannot bill for prolonged services for anything less than 30 minutes. But can we bill for prolonged services when the extra time is being provided by the MA and not the billing provider? So we would bill for 99214 based on documentation and medical decision making and then 99354 for the additional time the MA takes with the patient.

A1. Certainly not to CMS. The time needs to be spent by an MD/NP or someone who call bill time.

CMS states that ‘only the actual face-to-face time spent by the provider billing for the service can be considered in determining the level of E&M service. Time spent with the patient by other staff such as nurses and office assistants cannot be included in the face-to-face time.’

The CPT description is loose enough that you could take that position with a private payer, but it’s certainly not the spirit of the thing.

Q2. It seems that both Dr. A & Dr. B both rendered services to the same patient the same day and both subsequently billed for their respective services. One was an actual office visit, later in the day a Telehealth video visit. Can we combine the services and upcode? My biller says we can absorb one of the services into the other and possibly bill for a 99214/99215.

A2. The CPT manual and almost every payer restricts more than one unit of the office codes in the same clinic the same day as you know from the above. Under certain circumstances they might be ‘combined’, but it’s a difficult thing to do after the fact – after each encounter is documented. 

There is some potential there, but can you ask your biller ‘how’ she plans to ‘absorb one of the services into the other and possibly bill for a 99214/99215.’?

Any efforts to do this would likely require some amount of either fiddling with the notes in the form of ‘re-casting’ the first note within the second, or perhaps the first provider somehow knew to leave some documentation in the first note that would allow the second provider to build on it. This might be accomplished by documenting that first note by time. The first provider would have to agree to not bill the initial service in their own name. This usually doesn’t go down well. 

Q3. I have a question about HCC code capture in the note. When I do an annual wellness visit I often add the HCC at the end to increase our RAF score. Our auditor said we can’t do this if we don’t actively manage these things. Is there a way to do this legally?

A3. This is a really good question. It's actually a little deeper than it might seem. It's difficult for a reviewer to tell when you list a number of Dx in the A/P whether you are more mentioning them or managing them.

The real HCC/RAF method of scoring and payment relies on a provider accurately documenting the 'assessment' of all the patient’s conditions throughout an entire year. You can't do it all in one visit for some patients.

Many providers think the requirement is that they simply name the problems, that's not it. If you had simply named those problems, and didn't document any 'assessment' or management, an auditor may have thought an additional EM should have been billed there.

There really isn't a way to just 'name' them and get credit for HCC purposes - they are looking for management too.

Did the patient really just come in for the AWV? or IPPE? With no expectation you would address their problems? That's a little unusual.

But if you ‘list’ problems in the A/P – most readers will assume you assessed them, and want to bill that portion as well. If you don't want Medicare, or anyone to credit you with 'management' - and the attendant bill, then you'd need to identify that section of the A/P somehow. Maybe label it "HCC Problem List Only"

The deeper issue is that you have two separate reimbursement systems trying to coexist in the same chart - and using the same documentation of problem status to 'measure' or quantify a payment methodology. That's why they get mixed up.

_{About the Author}

_{Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.}