Medicare Compliance & Reimbursement

Answer 1: The answer depends on whether the two uro-gynecology practices share a tax ID number, says Barbara J.Cobuzzi, MBA, CPC,CPC-H, CPCP, CENTC, CHCC, senior coder and auditor for The Coding Network and president of CRN Healthcare Solutions in Tinton Falls, N.J.

"CMS specifically states that the patient is a new patient when seen under the same tax ID number by a doctor of a new specialty, not a doctor who does not share a chart," Cobuzzi says. "As a matter of fact, the other specialty may be sharing the chart with a different specialty. That is not the metric."

If the physicians do not share the same tax ID number, then they may have a case worth appealing, Cobuzzi says. "They need to talk to their MAC," Cobuzzi advises. "This could all be an issue of the conversion from carrier to MAC and the processing not happening quite right."

Answer 2: Medicare will only pay for an office visit if the patient is present, says Atlanta-based coding consultant Jay Neal.

Medicare requirements specify that the physician must meet face-to-face with the patient to report an established patient E/M visit (99211-99215). The only exception is if the physician must contact another individual (such as a spouse, parent, child, or other family member) to "secure background information to assist in diagnosis and treatment planning," according to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 70.1 (available at www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf).

The manual further states, "In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient's relatives or associates for this purpose, expenses of such interviews are properly chargeable as physician's services to the patient on whose behalf the information was secured. If the beneficiary is not an inpatient of a hospital, Part B reimbursement for such an interview is subject to the special limitation on payments for physicians' services in connection with mental, psychoneurotic, and personality disorders."

Key: The patient must be unable to provide the information himself. In this case, you may be able to report a low-level visit, but expect Medicare to reject the claim unless your documentation is especially clear as to the reason that contact with the family member was absolutely necessary.

Answer 3: Just because the encounter resulted in an inconclusive diagnosis, that does not mean you cannot report -- and be paid for -- the physician's services. Just make sure the documentation supports the patient's presenting symptoms.

ICD-9-CM coding guidelines (Section I.B.6. and Section IV.E) state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

Translation: If the doctor does not confirm emphysema, do not consider reporting any emphysema diagnoses.If the patient comes back for further testing that does reveal emphysema, then you can report an emphysema diagnosis. Instead, you'll probably look to 786.05 (Shortness of breath) and 786.07 (Wheezing).