Merging E&M Guidelines; Screening Codes; Phone/Internet Consults

Merging E&M Guidelines

Q: My office manager told me that I can use parts of the 1995 E&M guidelines and parts of the 1997 E&M guidelines in the same note. I think that is not allowed. Who is right?

A: To provide you with some guidance, let me quote CMS from an announcement it made in September 2013. CMS stated: "For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after Sept. 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service."

This is the only aspect of the two sets of guidelines that CMS has specifically stated can "crossover" from one set of guidelines to the next. However, since there is no difference in the decision-making areas, and the exams are the component of E&M that is usually distinct from one set of guidelines to the next, this change corrects a long-standing audit problem with E&M. Prior to this ruling, even when a patient presented for chronic disease management and had no "complaints," if a provider used a specialty exam from the 1997 guidelines, he needed to find the traditional HPI "elements." This often hindered providers when billing new patient visits.

The only area that CMS should still improve in regard to crossing over between the guidelines is to recognize the "status of one or two chronic problems" as equivalent to a "brief" history of present illness.

Screening Codes

Q: I am an internist and I have patients who need me to fill out biometric screening forms. This consists of writing the values of cholesterol screening, fasting glucose, height, and weight. To do this I need the lab values.

I recently gave a patient a prescription for the labs using V70.3 as the billing code. Her insurance stated that it wouldn't pay for the labs because I used the "wrong code." It suggested using a code for, and I quote, "universal routine medical blood work."

I have scoured the ICD-9 book without finding any mention of this code. Am I in the wrong for using V70.3? Am I missing the book carrying this and other mysterious "universal codes"?

A: There are no "universal" magical get everything paid codes, as I'm sure you suspect. V70.3 is specific to certain kinds of screening visits, such as those for marriages, prisons, school, sports, etc. This may be why that diagnosis code was denied.

V70.0 is the "routine general medical exam" code usually used. Maybe that's what the insurer is looking for. It's also entirely possible that the patient's plan may just not cover screening, although the Affordable Care Act makes that unlikely.

Phone/Internet Consults

Q: There are new codes for physician phone/Internet consults in the 2014 CPT Manual. Can these be used in both an inpatient and an outpatient setting? Does a physician have to be on both ends of the conversation?

A: You are referring to the codes 99446-99449 for inter-professional telephonic/Internet assessment and management service provided by a consultative physician, including a verbal or written report to the patient's treating/requesting physician or qualified healthcare professional. You select the codes based on time. Code 99446 is for five to 10 minutes of medical consultative discussion and review; 99447 is for 11 to 20 minutes; 99448 is for 21 to 30 minutes; and 99449 is for 31 minutes and more.

There is no language in the CPT that suggests that these codes must be used in a particular setting, but the fact that the full code description in the CPT suggests that both the outpatient and inpatient prolonged services codes can be used along with them tells us that the patient can be either outpatient or inpatient.

In regard to whether a physician must be on both ends of the conversation, the code description answers this question. It states that the consultative physician must include a verbal or written report to the patient's treating/requesting physician or qualified healthcare professional. CPT 2014 defines a "qualified healthcare professional" as anyone who can obtain an NPI number and bill directly in their own name.

Onsite Supervisory Requirements

Q: Our practice has operated under the assumption that a nurse who fills an order from a physician should bill under that physician. The thinking is that the nurse has a collaborative agreement with the physician and the physician does not need to be onsite when the order is completed. A colleague has questioned this. Is there an easy answer to this?

A: No. Many rules converge in a situation like this, including scope of practice, billing guidelines, and federal and state laws.

Your policy is that the physician does not need to be onsite when the order (the procedure, I assume) is completed. The general tone in the Medicare guidelines, however, is that a physician (it does not necessarily need to be the physician who initially ordered the service) must be onsite to meet the supervisory requirements.

Medicare Transmittal 1764 states:

"...Where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.

This does not mean, however, that to be considered incident to, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment. (However, the direct supervision requirement must still be met with respect to every nonphysician service.)

Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services."

Commercial insurers may not hold you to this standard, but Medicare will.

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.