Gastroenterology Coding Alert

Question: How do I bill for an established patient coming in for a medication refill?

AAPC Forum Participant

Answer: If the sole purpose for the office visit was to get a prescription refill, and no direct interaction occurred with the doctor or any other eligible healthcare professional, there wouldn’t be any service to charge. In fact, issuing a bill in such a situation would be viewed as upcoding, a practice that is unlawful under the Federal False Claims Act (FCA).

However, your practice might be able to bill under the following circumstance:

• If the patient also had questions about the treatment/ prescription
• If there were forms to fill out, which is sometimes the case for prescriptions that manage inflammatory bowel disease (IBD) or chronic GI pain. Many of those medications are controlled substances

In cases such as these, you’d probably use the ICD-10 code Z76.0 (Encounter for issue of repeat prescription) if appropriate, and CPT® code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional.). This approach assumes that the treating physician or a qualified health care professional (QHP) is not present at the encounter and a member of the provider’s clinical staff is working with the patient on resolving the patient’s issues by providing some assessment and management of the patient.

Note: Documentation for 99211 must include details of the assessment done by the staff and instructions given to patients under the supervision of the licensed provider.