General Surgery Coding Alert

Rest homes require a different POS code than nursing facilities

The financial health of many physician practices depends on coding E/M services correctly -- but many coders are puzzled by E/M coding rules. Use the following FAQ to clear up the most confusing E/M scenarios.

1. Report Pre-Op Exams With Caution

Question: When we schedule elective surgery on one of our patients, we also schedule a history and physical (H/P) to be done in our office by one of our physician's assistants. We had always believed that the H/P was part of the global service, and we have never charged for these. But we were recently advised that if this H/P is done more than 48 hours prior to the procedure, which it often is, that we can charge. Should we charge for such an H/P?

Answer: This question represents one of the many gray areas of coding, and the answer will depend on the specifics of your surgeon's visit.

-An H/P done the day before or the day of surgery is included in the global,- says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. But you-ll have to carefully examine the specifics of any visit two days or more before the surgery.

Suppose the physician saw the patient two months ago and at that visit decided to perform the surgery. Now the patient (who is in good general health) returns to your office for an H/P because the hospital requires it before the surgery. -If the H/P is only a hospital requirement and not medically necessary, then no matter when the surgeon performs it, it isn't billable,- Hvizdash says.

-If, however, the patient gets all the proper clearances, but the surgeon saw the patient when she was dealing with an active issue, the H/P might be necessary,- Hvizdash says. -The surgeon needs to make certain that the patient is healthy enough to withstand surgery. If this is the case, the H/P done more than a day before surgery is billable.-

Special note: The Office of Inspector General's 2007 Work Plan has targeted E/M services during the global period for special scrutiny, so you-ll only want to charge separately for a pre-op H/P if documentation supports medical necessity. -A good rule of thumb would be if the H/P is required by the surgeon (because of underlying medical conditions), it's probably billable. If required by the hospital, it's probably not billable,- Hvizdash says.

You can view the OIG's 2007 Work Plan at http://oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf.

2. Codes Differ for Rest Home, Nursing Facility

Question: Should I use the same codes when the surgeon performs an E/M service on a rest home patient as I would if the patient were in a nursing facility?

Answer: Unlike nursing facilities (NFs), rest homes do not have a medical component. Therefore, CPT includes different codes for E/M services performed on patients in each of these facilities.

When a general surgeon treats a rest home patient, you should use domiciliary, rest home or custodial care service codes. For a new patient, report 99324-99328 (Domiciliary or rest home visit for the evaluation and management of a new patient ...). Report established patient visits with 99334-99337 (Domiciliary or rest home visit for the evaluation and management of an established patient ...).

You should bill NF services with 99304-99318. Codes exist for initial (99304-99306, Initial nursing facility care, per day -) and subsequent care (99307-99310, Subsequent nursing facility care, per day -).

Remember also that you must use different place-of-service codes with 99324-99337 and 99304-99318. CPT classifies rest home, domiciliary and custodial care facilities as POS 33 (Custodial care facility). For claims involving NF care, use POS 32 (Nursing facility).

3. Calendar Date, Not Hours, Defines a -Day-

Question: A patient visits the surgeon for a previously scheduled E/M visit at 5 p.m. on Tuesday. The physician bills 99213 for that date. On Wednesday at 10 a.m., the patient returns to the same physician complaining of a new problem (for instance, abdominal pain). The surgeon evaluates the problem and bills 99213.

I know that I can only report one E/M -per day.- Because both services were in the same 24-hour period, should we combine the Wednesday visit into the Tuesday E/M and bill just one code?

Answer: CPT's descriptions refer to E/M services -per day,- not per 24-hour period, so you can report separate codes for your physician's services, says Stephen Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Patient Care.

-The day starts at midnight and ends at 11:59:59 p.m.,- Levinson says. -We all know that we are only allowed one inpatient E/M per day. Of course, we also know that if you admit a patient at 10 p.m. and submit a 99222 hospital admission code, it is completely appropriate to see the same patient at 7:30 a.m. the next -day- and submit a 99232 for subsequent hospital care.-

The same coding principles apply to outpatient services, allowing you to bill separate services on different dates, assuming that the physician's documentation meets CPT criteria to report the E/M visits on both dates.