# Payable visit or not?



## hthompson (Jan 19, 2012)

Pt came in to see FNP.  Had IMZ (Tdap) done and lab draw for something the pt will see the MD for at the next visit.

I want to bill 90715, V06.1 and 90471.

Is this billable as a nursing visit (99211) or just bill for the Immunization?

Can I also bill for the 36415, 99000 with the 272.4 if it's done by an RN?


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## ajs (Jan 20, 2012)

hthompson said:


> Pt came in to see FNP.  Had IMZ (Tdap) done and lab draw for something the pt will see the MD for at the next visit.
> 
> I want to bill 90715, V06.1 and 90471.
> 
> ...



Looks like just the immunization for billing.


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## btadlock1 (Jan 20, 2012)

hthompson said:


> Pt came in to see FNP.  Had IMZ (Tdap) done and lab draw for something the pt will see the MD for at the next visit.
> 
> I want to bill 90715, V06.1 and 90471.
> 
> ...



A couple of questions:
1. Patient's over 18? (I'm assuming so, with the lipid problem being mentioned)
2. Who decided to order the labs, and when? The MD, or the PA? Did the MD see the patient at all, or was it a standing order? 
3. Was the MD in the office at the time?
4. What kind of insurance is it?

If the patient's over 18, bill the FNP's services as 90471, 90715. Do not bill a 99211.
I'm curious about the lab - it makes it sound as though there was more to the visit than the vaccine, meaning that there may be room to bill an E/M - possibly even under the MD's name, under the right circumstances.


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## hthompson (Jan 23, 2012)

btadlock1 said:


> A couple of questions:
> 1. Patient's over 18? (I'm assuming so, with the lipid problem being mentioned)
> 2. Who decided to order the labs, and when? The MD, or the PA? Did the MD see the patient at all, or was it a standing order?
> 3. Was the MD in the office at the time?
> ...



Patient is over 18.  Insurance is Medicaid.  The lab was in preparation for a visit the following week.  

I think I'm comfortable billing for the IMZ only.  Now I'm curious if I can also bill the 36415, 99000 without a 99211?  That sounds better to me than trying to get a 99211 out of it, I just didn't want to throw any money away that we're entitled to.  I'm just not feeling the entitlement. 

The patient DID see an FNP, no MD on site.  That's how they do it in this clinic out in a remote location.  MD only sees patients on a monthly basis.


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## mitchellde (Jan 23, 2012)

You cannot bill the 99211 but I am curious where is the 272.4 dx coming from?  if the patient is on medication for hyperlipidemia then you would code the V58.83 and V58.69 for the 36415, if it is screening then use the V code for screening.


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## hthompson (Jan 23, 2012)

The FNP coded the 272.4.


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## mitchellde (Jan 23, 2012)

i see, but is it correct?  usually the V58.83 and V58.69 is the correct choice for labs prior to an annual exam.


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## hthompson (Jan 24, 2012)

I understand that it's incorrect, my point is about the validity of billing for it at all.  If I can't bill for the lab draw, the code doesn't matter, because it's not going anywhere 

Thanks for the info though, if I need to bill for labs.


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## mitchellde (Jan 24, 2012)

You can bill the lab draw, and it should be billed out, just not the 99211.  Even if your codes were not being billed out you are sending the specimens to the lab with a req and you have the diagnosis marked on there, so it needs to be the correct one.  Also since your MD is not on site you must bill using the FNP NPI in 24J and his/her signature in 31, not the MDs.  You can bill the 99000 but most will not pay it.


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## hthompson (Jan 24, 2012)

mitchellde said:


> You can bill the lab draw, and it should be billed out, just not the 99211.  Even if your codes were not being billed out you are sending the specimens to the lab with a req and you have the diagnosis marked on there, so it needs to be the correct one.  Also since your MD is not on site you must bill using the FNP NPI in 24J and his/her signature in 31, not the MDs.  You can bill the 99000 but most will not pay it.



I don't have any control over the codes that are on the lab req.  It's in a remote clinic and I don't even get the billing paperwork until 2 weeks after the fact.  

On that note, if the lab draw is for hyperlipidemia, why would I code for high risk meds.  I don't know whether or not the patient is on meds, as it was not stated.  I've never heard of coding for medication use for a lab draw unless it was insulin, lithium, anti-coagulation therapy, or something that was explicitly stated.  What references do you have to show me that I need to be coding for the V58 codes?  It seems that if the reason for the lab draw is to check the levels of the medication or the effects of the drug, that it would be logical, but it doesn't seem right to bill a V58 code everytime there is a lab draw and the condition that is being looked at is given as the diagnosis.  I haven't seen any guidance like that before and I've done this for 10 years full-time, so you're opening my eyes to something I've never thought of.


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## mitchellde (Jan 24, 2012)

It just depends on the reason for the lab draw but if a patient in on meds for hyperlipidemia then the lab test is to make sure the drug is being effective while not adversly affecting other organs, cholesterol meds can adversly affect the liver and must be monitored for this there fore it is a high risk med.  If it is screening for hyperlipidemia the we need to use a screening code, many people shy away from using V codes at all and will use the code for what they are screening for when the patient may not have the disease, it is so important to know this as the patient can have issues down the road related to how we code their record.  Rarely are drugs tests performed to check a disease we know they have, mainly we are checking the medication levels for therapeutic value.  Coding Clinics have covered this in numerous issues, one of the more recent was doing a bone density study for patients receiving phosamax and this too is to be coded with the V58.83 with the V58.69.  
Just something for you to watch for.


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