EM Coding Alert

Hint: Don't forget modifier 33.

Test your advance care planning (ACP) coding skills with this scenario from JoAnne Sheehan, CPC, CPB, CPPM, COC, CPC-I, senior instructor and coach at Certification Coaching Organization LLC in Oceanville, New Jersey, via her article "Advance Care Planning Services."

The case: "Jacob Marks, age 66, visits his physician, Dr. Lang, for his initial annual wellness visit (AWV), but he also wants Dr. Lang to examine his throat. Jacob has had a sore throat for three days, along with a low-grade fever. Nothing relieves his throat pain, but he has rested as much as possible because the fever has caused him to feel fatigued.

"Dr. Lang does an expanded problem-focused history and exam on Jacob with low complexity medical decision-making. Based upon the information he obtained from the visit, Dr. Lang also performs a rapid stress test in the office to determine if Jacob has strep throat. Dr. Lang prescribes Zithromax and tells Jacob to follow up in 10 days if his condition does not improve. The final diagnosis is streptococcal pharyngitis.

"For Jacob's initial wellness visit, Dr. Lang develops a personalized prevention help plan solely to prevent disease and disability based on Jacob's current health and risk factors. Jacob fills out a Health Risk Assessment as part of his visit. Dr. Lang reviews his medical and family history and comprises a current list of Jacob's prescriptions, as well as his current providers. Dr. Lang gives Jacob personalized health advice and a list of risk factors and treatment options for his persistent low back and leg pain, six month status-post L4-5 discectomy.

"In addition to the sick visit and the initial wellness exam, Dr. Lang asks Jacob if he has given any thought to putting together documents for ACP since he is already in his sixty-sixth year and has been receiving ongoing treatment for debilitating back and bilateral leg pain for fifteen years. Dr. Lang has concerns that Jacob is at high risk for falling. Dr. Lang and Jacob discuss ACP options for 35 minutes, and Dr. Lang presents Jacob with a healthcare power of attorney document to be completed as well as the name of an attorney who specializes in living wills and documentation for physician orders aimed at his future scope of treatment. Jacob is receptive to the information and plans to contact the attorney."

Test yourself: Provided all of this information is documented in the medical record, what services can you report for this encounter?

How did you do? Check your answers against this solution.

The coding solution: You could submit the following codes on your claim:

First, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the office visit related to the strep throat diagnosis. You'll need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to identify 99213 as a significant, separately identifiable E/M service by the same physician on the same day as another service. You'll use diagnosis code J02.0 (Streptococcal pharyngitis).

Next, report 87880 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) for the rapid strep test, also with diagnosis code J02.0. Add modifier QW (Clia waived test) since 87880 is designated as a CLIA-waived test.

For the annual wellness check, report G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit). You won't need a modifier on this code. Attach diagnosis code Z00.0 (Encounter for general adult medical examination).

Your final CPT^® code will be 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate), which represents the ACP service. Assign the following diagnosis codes to this service:

• M54.5 (Low back pain)
• M79.604 (Pain in right leg)
• M79.605 (Pain in left leg)
• Z98.890 (Other specified postprocedural states).

Don't miss: Remember that you need to append modifier 33 (Preventive services) to 99497 because the ACP was part of the patient's preventive annual wellness visit, Sheehan says. "By adding modifier 33, the patient will not be charged co-insurance, a co-payment, or a deductible for this part of his care," she adds

Make certain, too, that the diagnoses are appropriated assigned to each of the services. For example, the Z00.0 would not be reported for the 99213-25.