Lack of Obtainable Information; Family Conference; Chart Review

Lack of Obtainable Information

Q: When a provider sees a patient who is incapable of giving a complete history for some reason, (i.e., if a first-time patient is emergently admitted to the ICU and is experiencing altered mental status or is unconscious), do we need to have the full history to bill a 99222 or 99223? Or, is the explanation for lack of obtainable information sufficient to meet the requirements for the higher-level codes?

A: The 99285 ER code is the only code in the CPT manual that allows for history or exam "within the constraints imposed by the urgency of the patient's clinical condition." This is known as the high-acuity caveat.

However, The Medicare documentation guidelines state that, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history."

The expectation then being that the history requirement may be lessened if the explanation makes sense. But the documentation does not actually state that the requirement is relaxed.

Family Conference/Patient Absence

Q: If a patient does not come to the office, but a family member comes instead and wants to discuss the patient's health conditions, can you bill for the consultation based on the history and decision-making parts (2 out of 3)?

A: Medicare requires that the beneficiary (patient) be present in the office in order to bill. So forget any of this for Medicare.

The CPT manual states "patient and/or family" is relative to billing by counseling time on most E&M codes.

Theoretically, unless a commercial payer has stated that the patient needs to be present, you could use the looser CPT definition. But the better course is to have a flat cash fee for a "family conference."

Chart Review

Q: Is documentation of clubbing acceptable for the musculoskeletal system in a chart review? I have heard it described as cardiopulmonary. I get that, but isn't it really a cardiopulmonary cause with a musculoskeletal manifestation?

I was looking at the general multisystem examination. Under the musculoskeletal section, the second bullet point is "Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)."

Wouldn't that make it possible to use clubbing as an exam element for musculoskeletal?

A: Yes, the 1997 exam guidelines do indicate that clubbing and cyanosis are in the musculoskeletal system - and you can count them as such. But, the bigger issue is when the exam area is labeled as "extremities," followed usually by the CCE comment. Although the finding is technically musculoskeletal as above - it doesn't look like it - it looks more like a cardiorespiratory finding in an extremity and may not be counted as a separate system by federal or other auditors.

Hyperlipidemia in the ROS

Q: What's your take on hyperlipidemia for the endocrine system in the ROS?

A: On hyperlipidemia as part of ENDO in the ROS - I don't think it fits - it's not an endocrine problem!

Services Provided by a Contractor

Q: I own a company that provides home sleep testing services. We are Medicare enrolled and Joint Commission accredited. Physicians can order our service for their patients; we provide the testing and forward the results to a sleep physician for interpretation. The original physician then receives the results and can initiate therapy for the patient. We bill Medicare but are not currently in network with all the major insurance companies.

Can a physician's office bill for the home sleep testing ordered by the physician? We are meeting some resistance with physician offices that say they cannot bill for services provided by another business or contract service. However, I know of many offices that do just that (such as neurologists who have EEGs performed in their office by a contract service). Thanks for any direction you can offer.

A: The basic Medicare reimbursement rules impose strict requirements regarding who may bill for a service performed by another. These rules are referred to as the "reassignment rules" because the clinician who accepts assignment of the claim reassigns it to another entity. The rules also implicate diagnostic testing arrangements.

The 2002 Medicare Fee Schedule liberalized the "incident to" rules, so it is no longer necessary that ancillary personnel who are involved in the testing be W-2 employees or even leased employees. The group may bill for services provided by independent-contractor MLPs who reassign their right to payment to the physician group, but only for the services they provide on the group's premises. The group may not bill for services these clinicians provide off-site at a hospital, at an ambulatory surgery center, or even on a house call.

A group may not bill globally for a service if it has purchased the professional component/interpretation from an outside consultant who reads the study off-site. A specific Medicare reassignment rule prohibits this type of arrangement. The Medicare Carriers Manual states that a family practice group may only bill globally for services that involve an outside consultant if that physician reassigns his or her right to payment to the group (becomes a member of the group for these purposes) and performs the interpretations at the office of the family physicians.

You should also be aware of a relevant provision in the Social Security Act that prohibits a physician from marking up a purchased technical component. According to the Medicare Carriers Manual, previously, the technical component was not considered purchased if the service was provided under the direct supervision of the physician, which was restricted to mean that the physician was in the office suite and the ancillary personnel were the physician's or the practice's W-2 employees. Because this relationship is no longer required to meet direct supervision requirements, now the waters are murkier, particularly if the physician obtains the use of equipment and a technician from an outside vendor and pays the vendor per study. In such an arrangement, the likelihood that the technical component was purchased is far greater, and the family physician can bill only the actual acquisition cost of the technical component or the fee schedule amount, whichever is less. A violation of this rule is subject to a $2,000 civil money penalty for each improper claim. Therefore, it is far better to have direct control (direct lease or purchase) of diagnostic equipment and engage your own technicians directly than to obtain them from outside vendors.

As far as any given commercial payer goes, or those payers that you are not contracted with, you should ask them what their requirements are.

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 September 2011 issue of Physicians Practice.