Medicare Compliance & Reimbursement

Question: A 25-year-old new patient reports to the gastroenterologist complaining of consistent pain in the upper left quadrant of his torso; he rates the pain as 9 on a scale of 10. The provider performs an E/M service that includes a detailed history and examination, along with moderate medical decision making (MDM), and decides that the patient needs a screening colonoscopy. While the nurse practitioner (NP) is prepping the patient for the procedure, he begins to question if he really needs the screening. The NP halts the preparations to speak with the patient. She explains to him that his stomach pain is unlikely to abate unless the gastroenterologist can pinpoint the problem with the colonoscopy results. The patient ultimately consents to the colonoscopy. The physician performs a diagnostic colonoscopy and takes two specimens for further examination. Notes indicate that outside the E/M and the colonoscopy, the NP spent 24 minutes counseling the patient. Is there a way to get paid for the NP’s extra time?

Answer: You should be able to report the extra counseling time with the new prolonged services codes designed for non-physicians. Payment for the time is, however, another issue altogether.

On the claim, report 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for the colonoscopy. Then, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity…) for the E/M with 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) appended to show that the E/M and the colonoscopy were separate services.

Finally, report +99415 (Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour [List separately in addition to code for outpatient Evaluation and Management service]) for the NP’s extra time.

Guidance: Since +99415 and +99416 (… each additional 30 minutes [List separately in addition to code for prolonged services]) are new for 2016, there’s no news on whether payers will actually accept and pay on these codes. Check with your payer before submitting the claim. You should use them, however, as CPT^® included them in the code book and as they fit your situation.

If payers do reimburse for +99415 and +99416, including modifier 25 becomes even more important in your scenario. Forget modifier 25 on the claim, and the payer could deny 99203; and if the payer denies 99203, it will certainly deny +99415.

Also, keep in mind that the 99203 service code has a time suggestion of 30 minutes. If the same provider is reporting the visit and the counseling, you should consider the counseling/coordination of care caveat.