Doctors Office Visit Bill by zqu34709

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Doctors Office Visit Bill document sample

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									E&M Coding Errors That Cost
      You Money Everyday
    Steven A. Adams, CPC, CPC-H, COA

  Because your patients come first.
   Because your patients come first.
                  Doing It Right!
                  Five Steps to Reimbursement


 1. Understand the Guidelines
 2. Perform the Service
 3. Document What You Did (according to
    the guidelines)
 4. Bill what you documented
 5. Collect what you billed




Because your patients come first.
 Because your patients come first.
               Table of Contents

         • Outpatient Scenarios
         • Observation
         • Inpatient Scenarios
         • Consultation Scenarios
         • ER Critical Care Scenarios
         • Question & Answer



Because your patients come first.
 Because your patients come first.
            Outpatient Scenarios


The time to repair the roof is when the sun
                is shining




Because your patients come first.
 Because your patients come first.
           Outpatient Scenarios
 • Dr. Riley went to a conference and is
   convinced that when documentation rules
   read 2 of 3 requirements he can document a
   detailed history, detailed examination, and
   low complexity and still bill a level 99214.
   Does medical necessity really drive code
   selection.
 • The rule states 2 of 3 - so Necessity
                                                1
   isn’t important.


Because your patients come first.
 Because your patients come first.
                        Answer
Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a CPT code. It would not be medically
necessary or appropriate to bill a higher level of
evaluation and management service when a lower level
of service is warranted. The volume of documentation
should not be the primary influence upon which a
specific level of service is billed. Documentation should
support the level of service reported. The service should
be documented during, or as soon as practicable after it
is provided in order to maintain an accurate medical
record.



Because your patients come first.
 Because your patients come first.
           Outpatient Scenarios
 • Dr. sees patient for f/u and spends 40
   minutes with the patient talking about an
   upcoming surgery. Only thing in the note
   states “lengthy discussion with patient.”
   Can you select E&M codes based upon that
   statement?
 • Unless you document a history, exam and
   medical decision making, you can’t select
                                             2
   an E&M code without committing fraud.


Because your patients come first.
 Because your patients come first.
                           Answer
Selection Of Level Of Evaluation and Management
Service Based On Duration Of Coordination Of Care
and/or Counseling.--Advise physicians that when
counseling and/or coordination of care dominates (more
than 50 percent) the face-to-face physician/patient
encounter or the floor time (in the case of inpatient services),
time is the key or controlling factor in selecting the level of
service. In general, to bill an E/M code, the physician must
complete at least 2 out of 3 criteria applicable to the
type/level of service provided. However, the physician may
document time spent with the patient in conjunction with the
medical decision-making involved and a description of the
coordination of care or counseling provided. Documentation
must be in sufficient detail to support the claim.

   Because your patients come first.
    Because your patients come first.
           Outpatient Scenarios
 • Dr. Smith is an Dermatologist who routinely
   brings her Medicare patients back to the
   office on a separate date to perform minor
   surgery so the claim will be paid. She states
   she’s confused about the “25” modifier.
 • Since you can’t bill an office visit and
   surgery on the same day, you have to
   bring them back.
                                                   4


Because your patients come first.
 Because your patients come first.
                         Answer
CPT Modifier 25-Significant Evaluation and
Management Service By Same Physician On Date of
Global Procedure.--Pay for an evaluation and management
service provided on the day of a procedure with a global
fee period if the physician indicates that the service is for a
significant, separately identifiable evaluation and
management service that is above and beyond the pre-
and post-operative work of the procedure.




 Because your patients come first.
  Because your patients come first.
           Outpatient Scenarios
 • Dr. Black left his practice is Warner Robbins
   and moved down the road to Macon. He is
   seeing his former patients at the new
   practice and bills them as “new patients”
   because he has a new Tax ID number.
 • Since he has to create a new chart, he has
   extra costs, and that’s why he can bill as
   new patient.
                                                   5


Because your patients come first.
 Because your patients come first.
                              Answer
Definition of New Patient For Selection Of Visit Code.--Interpret the
phrase "new patient" to mean a patient who has not received any
professional services from the physician within the previous 3 years.

If no face to face encounter has previously occurred between the physician
and the patient, then the patient may be coded as a new patient the first
time a face to face encounter does occur. For example, if a professional
component of a previous procedure is billed in a 3 year time period, e.g., a
lab interpretation is billed but a face to face encounter does not take place,
then this patient remains a new patient for whenever the initial evaluation
and management service occurs. An interpretation of a diagnostic test,
reading an x-ray or EKG etc., in the absence of a face to face encounter
does not affect the new patient designation.




    Because your patients come first.
     Because your patients come first.
           Outpatient Scenarios
 • Dr. Cohen sees a patient in the morning for
   HTN. At 5pm the patient presents to the
   office with a large laceration that leads to a
   hospital admission. Dr. Cohen submitted a
   claim for 2 E&M codes on the same day - an
   office visit and hospital admission.
 • You can never bill an office and hospital
   visit on the same day.
                                                    5


Because your patients come first.
 Because your patients come first.
                         Answer
Office/Outpatient Visits Provided On Same Day For
Unrelated Problems.--Do not pay two office visits billed by
a physician for the same beneficiary on the same day
unless the physician documents that the visits were for
unrelated problems in the office or outpatient setting which
could not be provided during the same encounter (e.g.,
office visit for blood pressure medication evaluation,
followed 5 hours later by a visit for evaluation of leg pain
following an accident).




 Because your patients come first.
  Because your patients come first.
           Outpatient Scenarios
 • Dr. Elliott was told at a conference to have
   his nurse bill code (99211) when she gives
   a patient an injection on a date when the
   patient is not see the physician. He was told
   the nurse code pays more than a standard
   therapeutic injection code (90782).
 • Since 99211 pays more than 90782, my rep
   told me its ok to bill the 99211.
                                                   5


Because your patients come first.
 Because your patients come first.
                         Answer
Injection and Evaluation and Management Code Billed
Separately on Same Day of Service.--Advise physicians
that CPT code 99211 cannot be used to report a visit solely
for the purpose of receiving an injection which meets the
definition of CPT codes 90782, 90783, 90784, or 90788.
Do not pay CPT codes 90782, 90783, 90784, or 90788 if
any other physician fee schedule service was rendered.
The drug is billed as a J code, whether the injection is
separately billable or not.




 Because your patients come first.
  Because your patients come first.
           Outpatient Scenarios
 • Dr. Rawlings is a busy OBGYN who sees
   several women needing counseling for
   hormone replacement therapy. Her initial
   visit takes approximately 120 minutes and
   she bills these as a level 4 new patient visit
   (99204).
 • She could use a 21 or 22 modifier to show
   this took longer than usual                    16 /
                                                  17

Because your patients come first.
 Because your patients come first.
                         Answer
Code    Time for Code                 99354   99354 & 99355

99201          10                       40            85
99202          20                       50            95
99203          30                       60            105
99204          45                       75            120
99205          60                       90            135
99212          10                       40            85
99213          15                       45            90
99214          25                       55            100
99215          40                       70            115
99241          15                       45            90
99242          30                       60            105
99243          40                       70            115
99244          60                       90            135
99245          80                       110           155


 Because your patients come first.
  Because your patients come first.
                     Observation
                      Scenarios

 Forgive your enemies, but never forget their
                  names.




Because your patients come first.
 Because your patients come first.
         Observation Scenarios
 • Dr. Hancock wants to know what needs to
   be documented in order to show his patient
   was in observation status at the hospital.




                                                6


Because your patients come first.
 Because your patients come first.
                        Answer
For a physician to bill the initial observation care
codes, there must be a medical observation record
for the patient which contains dated and timed
physician’s admitting orders regarding the care the
patient is to receive while in observation, nursing notes,
and progress notes prepared by the physician while the
patient was in observation status. This record must be
in addition to any record prepared as a result of an
emergency department or outpatient clinic encounter.




Because your patients come first.
 Because your patients come first.
         Observation Scenarios
 • Dr. Mays puts his pregnant patient in
   observation for pre-mature labor at 9AM on
   Monday. Later that day the patient is
   discharged with an appointment to f/u with
   Dr. Mays next week. He selects CPT code
   99219 to reflect this service.
 • He should have picked his observation and
   his discharge - he did two services.
                                                6


Because your patients come first.
 Because your patients come first.
                        Answer
Physician Billing For Observation Care Following
Admission To Observation.--If the patient is
discharged on the same date as admission to
observation, pay only the initial observation care code
because that code represents a full day of care. 99234,
99235, 99236 wrong in MCM




Because your patients come first.
 Because your patients come first.
         Observation Scenarios
   • Dr. Ramos has a patient in observation
     for three days. On day one he bills an
     initial observation code (99218) and day
     three an observation discharge code
     (99217). On day two Dr. Ramos selects
     a subsequent hospital code 99214.
   • 99214 can only be used in the office and
     not in the hospital
                                                6


Because your patients come first.
 Because your patients come first.
                        Answer
In the rare circumstance when a patient is held in
observation status for more than two calendar
dates, the physician must bill subsequent services
furnished before the date of discharge using the
outpatient/office visit codes. The physician may not use
the subsequent hospital care codes since the patient is
not an inpatient of the hospital.




Because your patients come first.
 Because your patients come first.
         Observation Scenarios
 • Dr. Riley sees puts her patient in
   observation on Monday morning and then
   admits the patient to the hospital later that
   night. She coded both the initial observation
   code (99219) and initial hospital admission
   code (99222) on the same day.
 • If patient is admitted 3 or more hours
   after their office visit you can bill both
                                                 6
   codes with a -59 modifier.


Because your patients come first.
 Because your patients come first.
                        Answer
Admission To Inpatient Status From Observation.--If
the same physician who admitted a patient to
observation status also admits the patient to inpatient
status from observation before the end of the date on
which the patient was admitted to observation, pay only
an initial hospital visit for the evaluation and
management services provided on that date.




Because your patients come first.
 Because your patients come first.
            Observation Scenarios
• Dr. Woods places a patient in observation
  on Monday and admits them to the hospital
  on Tuesday. She selects the initial
  observation code (99219) on Monday. For
  Tuesday she selects an observation
  discharge code (99217) and initial hospital
  care code (99222).
• If you discharge from observation and admit
  to hospital you can bill all codes since this is   6
  a different sight of service 21 vs 22.

   Because your patients come first.
    Because your patients come first.
                        Answer
If the patient is admitted to inpatient status from
observation subsequent to the date of admission to
observation, the physician must bill an initial hospital
visit for the services provided on that date. The
physician may not bill the hospital observation
discharge management code (code 99217) or an
outpatient/office visit for the care provided in
observation on the date of admission to inpatient status.




Because your patients come first.
 Because your patients come first.
              Inpatient Scenarios


   We must use time as a tool, not a crutch.




Because your patients come first.
 Because your patients come first.
             Inpatient Scenarios
 • Dr. Bhagat admits her patient in morning,
   and must f/u with the patient later in the day
   because of increased N/V/D. She billed for
   both her admission (99223) and subsequent
   hospital visit (99233).
 • When a separate visit occurs in the
   afternoon, after admission, you can bill
   the second visit with a -59 modifier if you
                                                  8
   have an additional diagnosis.


Because your patients come first.
 Because your patients come first.
                        Answer
Two Hospital Visits Same Day (same physician).--
Pay a physician for only one hospital visit per day for
the same patient, whether the problems seen during the
encounters are related or not. Advise physicians that
they may not report two hospital visits on the same day
to the same patient. The inpatient hospital visit
descriptors contain the phrase "per day" which means
that the code and the payment established for the code
represent all services provided on that date. The
physician should select a code that reflects all services
provided during the date of the service.




Because your patients come first.
 Because your patients come first.
             Inpatient Scenarios
 • Dr. Bhagat sees her patient in the morning
   for her pre-term labor and another physician
   not in her group - Dr. Shaw - who is
   covering call that night, is called into the
   hospital because the patient has increased
   abdominal pain unrelated to the pre-term
   labor. Dr. Bhagat and Dr. Shaw both bill for
   their services.
 • Dr. Shaw is not in Bhagat’s group and has 8
   a different provider number so he can bill

Because your patients come first.
 Because your patients come first.
                        Answer
Hospital Visits Same Day But By Different
Physicians.--In a hospital inpatient situation involving
one physician covering for another, if physician A sees
the patient in the morning and physician B, who is
covering for A, sees the same patient in the evening, do
not pay physician B for the second visit. The hospital
visit descriptors include the phrase "per day" meaning
care for the day.




Because your patients come first.
 Because your patients come first.
             Inpatient Scenarios
 • Dr. Howard admits his patient into the
   hospital at 1:00AM for dizziness. At 10PM
   he discharges the patient and bills an initial
   hospital code of 99223 and discharge of
   99238.
 • Patient is in for less than 24 hours so we
   can bill for both the admission and
   discharge on same day if we use a -25
                                                  8
   modifier to show a separately identifiable
   service in the morning.
Because your patients come first.
 Because your patients come first.
                        Answer
Initial Hospital Care and Discharge on Same Day.--
Pay only the initial hospital care code when a patient is
admitted as an inpatient and discharged on the same
day. Do not pay the hospital discharge management
code on the date of admission. Instruct physicians that
they may not bill for both an initial hospital care code
and hospital discharge management code on the same
date. – 99234, 99235, or 99236) – wrong in MCM




Because your patients come first.
 Because your patients come first.
               Inpatient Scenarios
• Dr. Strickland discharges his patient from
  the hospital and admits them to an area
  nursing home on the same day. Dr.
  Strickland bills for the hospital discharge
  only and does not bill for the nursing home
  admission.
• Doctors can never bill two E&M Codes on
  the same day - you’ve already taught us
  that.                                         9


  Because your patients come first.
   Because your patients come first.
                        Answer
Hospital Discharge Management (CPT Codes 99238
and 99239) and Nursing Facility Admission Code
When Patient Is Discharged From Hospital and
Admitted To Nursing Facility on Same Day.--Pay the
hospital discharge code (codes 99238 or 99239) in
addition to a nursing facility admission code when they
are billed by the same physician with the same date of
service.




Because your patients come first.
 Because your patients come first.
                    Consultation
                     Scenarios

We stand for freedom. That is our conviction
for ourselves; that is our only commitment to
                    others.




Because your patients come first.
 Because your patients come first.
        Consultation Scenarios
 • Dr. King is a Gynecologist who was told to
   never bill a consult code if a patient
   presented to him with an established
   diagnosis.
 • Consultations can only be billed on patients
   who present without a specific diagnosis.


                                                  10


Because your patients come first.
 Because your patients come first.
                         Answer
Consultation Versus Visit.--Pay for a consultation when all of the
criteria for the use of a consultation code are met:

       (1) Specifically, a consultation is distinguished from a visit
       because it is provided by a physician whose opinion or
       advice regarding evaluation and/or management of a
       specific problem is requested by another physician or other
       appropriate source (unless it is a patient-generated
       confirmatory consultation).

       (2) A request for a consultation from an appropriate source
       and the need for consultation must be documented in the
       patient’s medical record.

       (3) After the consultation is provided, the consultant
       prepares a written report of his/her findings which is
       provided to the referring physician.

Because your patients come first.
 Because your patients come first.
        Consultation Scenarios
 • Dr. Kusuma is a GYN doc who ordered a
   diagnostic endoscopy procedure on a
   patient with severe abdominal pain.
 • When a doctor decides to treat a patient
   during the initial visit, he is not able to bill a
   consultation code. This is abuse and would
   be easily detected during a review.
                                                        10


Because your patients come first.
 Because your patients come first.
                        Answer
A physician consultant may initiate diagnostic
and/or therapeutic services at an initial or subsequent
visit. Subsequent visits (not performed to complete the
initial consultation) to manage a portion or all of the
patient’s condition should be reported as established
patient office visit or subsequent hospital care,
depending on the setting.




Because your patients come first.
 Because your patients come first.
        Consultation Scenarios
 • Drs. Johnson and Adams are Orthopedic
   surgeons in the same group. Dr. Johnson
   does hands and Dr. Adams does legs. Dr.
   Johnson requested a consult from Dr.
   Adams regarding a patients knees. Dr.
   Adams billed his visit with the patient as an
   established patient visit 99213.
 • Of course doctors in the same group can
                                                 10
   bill consultations, even if they are the
   same specialty.
Because your patients come first.
 Because your patients come first.
                        Answer
Consultations Requested by Members of Same
Group.--Pay for a consultation if one physician in a
group practice requests a consultation from another
physician in the same group practice as long as all of
the requirements for use of the CPT consultation codes
are met. (See §§15506A and 15501.H.)




Because your patients come first.
 Because your patients come first.
        Consultation Scenarios
 • Dr. Wiloghby is an interest in Augusta. On
   any given day he is asked to do a pre-
   operative consult on his patients needing
   cataract surgery. Because these patients
   have already been seen by Dr. Wiloghby, he
   bills them as 99214 - established patient
   visits.
 • You can not bill a consultation on your
                                              11
   own patient. Consultations are only for
   new patients to your office.
Because your patients come first.
 Because your patients come first.
                        Answer
    Consultation for Preoperative Clearance.--Pay
    for the appropriate consultation code for a pre-
    operative consultation for a new or established
    patient performed by any physician at the
    request of a surgeon, as long as all of the
    requirements for billing the consultation codes
    are met.




Because your patients come first.
 Because your patients come first.
               ER & Critical Care
                  Scenarios

       We need men who can dream of
           things that never were.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Murphy is an Ophthalmologist and
   receives a call from one of his patients
   complaining of severe floaters. Dr. Murphy
   is playing golf and does not want to drive all
   the way back to the office so he asks the
   patient to meet him in the ER. The patient
   does not register with the hospital. Dr.
   Murphy bills an ER code (99283).
 • The only codes you can use in the ER           12
   are ER codes.

Because your patients come first.
 Because your patients come first.
                        Answer
Advise physicians that if the physician asks the
patient to meet him or her in the emergency
department as an alternative to the physician’s office
and the patient is not registered as a patient in the
emergency department, the physician should bill the
appropriate office/outpatient visit codes.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Collins tells his patient to go to the ER
   after a call complaining of chest pain. The
   ER doctor subsequently calls Dr. Collins to
   come to the ER and offer his advise as to
   whether the patient should be admitted or
   sent home. Dr. Collins admits the patient
   and bills both an ER visit and hospital
   admission.
 • Because he has to do an admit H&P he bills both
   codes with the place of service as ER and         12
   Inpatient hospital and his UPIN #.


Because your patients come first.
 Because your patients come first.
                        Answer
If the patient is admitted to the hospital by the
patient’s personal physician, then the patient’s
regular physician should bill only the appropriate level of
the initial hospital care (codes 99221-99223) because
all evaluation and management services provided by
that physician in conjunction with that admission are
considered part of the initial hospital care when
performed on the same date as the admission. The ED
physician who saw the patient in the emergency
department should bill the appropriate level of the ED
codes.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Collins tells his patient to go to the ER
   after a call complaining of chest pain. The
   ER doctor subsequently calls Dr. Collins to
   come to the ER and offer his advise as to
   whether the patient should be admitted or
   sent home. The patient is discharged by the
   ER physician. Dr. Collins bills an
   outpatient consult for all his trouble.
 • Since his opinion was requested by ER         12
   doctor he can bill an outpatient consult.

Because your patients come first.
 Because your patients come first.
                         Answer
If the ED physician, based on the advice of the patient’s
personal physician who came to the emergency department to
see the patient, sends the patient home, then the ED physician
should bill the appropriate level of emergency department service.
The patient’s personal physician should also bill the level of
emergency department code that describes the service he or she
provided in the emergency department. The patient’s personal
physician would not bill a consultation because he or she is not
providing information to the emergency department physician for
his or her use in treating the patient. If the patient’s personal
physician does not come to the hospital to see the patient, but only
advises the emergency department physician by telephone, then
the patient’s personal physician may not bill.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Collins is called to the ER because of a
   patient complaining of chest pain. He sees
   the patient, renders his opinion and advice,
   and bills an outpatient consultation (99245).
 • Since the ER is in the hospital, he should bill
   the hospital consultation codes 99255.


                                                     13


Because your patients come first.
 Because your patients come first.
                          Answer
Physician Requests Another Physician To See the Patient In
Emergency Department Or Office/Outpatient Setting.--If the
emergency department physician requests that another physician
evaluate a given patient, the other physician should bill a
consultation if the criteria for consultation (see 15506A) are met. If
the criteria for a consultation are not met and the patient is
discharged from the Emergency Department or admitted to the
hospital by another physician, the physician contacted by the
Emergency Department physician should bill an emergency
department visit. If the consulted physician admits the patient to the
hospital and the criteria for a consultation are not met, he/she
should bill an initial hospital care code.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • When deciding on how much time to bill for
   critical care, you can only use that time
   immediately at the bedside of the patient.
 • Correct.




                                                13


Because your patients come first.
 Because your patients come first.
                        Answer
Constant Attendance or Constant Attention as
Prerequisite for Use of Critical Care Codes.--Advise
physicians that the duration of critical care to be
reported is the time the physician spent working on the
critical care patient’s case, whether that time was spent
at the immediate bedside or elsewhere on the floor, but
immediately available to the patient.




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Hancock is providing critical care
   services for Ms. Linda. He spends 40
   minutes at her bed side and 35 minutes
   speaking to her primary care physician
   reviewing medications, labs, etc. while on
   the unit. He bills his service as 99291.
 • No, he should bill 99291 & 99292.
                                                14


Because your patients come first.
 Because your patients come first.
                        Answer
Total Duration of Critical Care Code(s)
a.     Less than 30 minutes 99232 or 99233
b.     30-74 minutes 99291 x 1
c.     75-104         minutes 99291 x 1 and 99292 x 1
d.     105-134        minutes 99291 x 1 and 99292 x 2
e.     135-164        minutes 99291 x 1 and 99292 x 3
f.     165-194        minutes 99291 x 1 and 99292 x 4




Because your patients come first.
 Because your patients come first.
    ER / Critical Care Scenarios
 • Dr. Jones is asked to consult on a patient in
   the ER in severe respiratory distress. Dr.
   Jones spends 105 minutes of critical care
   services and admits the patient. She bills
   her consultation (99245), critical care
   (99291, 99292) and the admission (99223).
 • Correct, you can bill critical care with
   other E&M codes on the same day.
                                                   14


Because your patients come first.
 Because your patients come first.
                        Answer
Critical Care Service and other Evaluation and
Management Services Provided on Same Day.--If
critical care is required upon the patient’s presentation
to the emergency department, only critical care codes
99291-99292 may be reported. Emergency department
codes will not be paid for the same day. If there is a
hospital or office/outpatient evaluation and management
service furnished early in the day and at that time the
patient does not require critical care, but the patient
requires critical care later in the day, both critical care
and the evaluation and management service may be
paid.



Because your patients come first.
 Because your patients come first.
                      Resources


The American, by nature, is optimistic. He
is experimental, an inventor and a builder
who builds best when called upon to build
                 greatly.



Because your patients come first.
 Because your patients come first.
               John F. Kennedy




Because your patients come first.
 Because your patients come first.
                  Doing It Right!
                  Five Steps to Reimbursement


 1. Understand the Guidelines
 2. Perform the Service
 3. Document What You Did (according to
    the guidelines)
 4. Bill what you documented
 5. Collect what you billed




Because your patients come first.
 Because your patients come first.
Questions?



Because your patients come first.
 Because your patients come first.

								
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