Primary Care Coding Alert

Separate chart notes, diagnoses justify office visit reimbursement

You can overturn denials for office visits with catheterization -- and even avoid them -- if your documentation and diagnoses substantiate the E/M's separate nature.

Because 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) is no longer a "starred procedure," payers now include a minor pre-, intra-, and post-E/M service with the catheterization. Therefore, you should code an office visit (99201-99215, Office or other outpatient visit for a new or established patient ...) in addition to the urine catheterization code only when your FP documents an E/M service beyond what the scheduled catheterization includes.

Insurers, however, may still bundle 992xx into 51701. The solution: Provide iron-clad documentation with diagnoses that justify your office visit payment.

1. Include 3 E/M Findings in Office Note

You should encourage your FP to write a separate office visit note. If you have to appeal for your office visit payment, separate documentation will substantiate that your physician couldn't perform the catheterization without the office visit, says Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology for the Health Science Center at the State University of New York in Stony Brook.

The office note should describe the E/M service. Your physician should include the child's history of present illness, review of systems, and his physical examination findings, Ferragamo says.

2. Link Preliminary Dx, Plan to E/M

Make sure that your FP includes an initial assessment and plan in the office note. You can then use the pre-procedure diagnosis with the office visit to show the payer that the E/M service led to your FP's decision.

Example: Suppose a 9-month-old girl presents with fever and symptoms that suggest a urinary tract infection. The FP decides to perform a urine catheterization to obtain a sterile urine sample for urinalysis and culture. His assessment notes state, "Fever of unknown origin," (780.6, Fever) and his plan reads, "Need to do a urine catheterization to obtain sterile urine sample for urinalysis and culture."

Right way: Link the preprocedure diagnosis to 99201-99215. This informs the payer that the physician performed the E/M service to evaluate the patient's fever.

Depending on payer preference, you should also append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery) to the office visit code. "Most insurers follow Medicare's lead and want modifier -25 on minor procedures," says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine FPs, in Escondido, Calif.

Some payers, however, may prefer that you use modifier -57 to indicate decision for surgery, rather than modifier -25 for a separate service. So check your major insurance companies'policies.

3. Submit 51701 With Final Dx

Your FP should write a separate paragraph or use a different sheet of paper for his catheterization procedure note. "This will make it easy for a payer to see that the E/M service is separate from the surgery," Darling says. If you have to appeal for 99201-99215 payment, the separate note should boost your reimbursement odds.

In the procedure section of the note, your FP should record his final assessment and plan. For instance, in his final assessment, the physician may determine that the child has a urinary tract infection (599.0, Urinary tract infection, site not specified), Ferragamo says. His plan would then describe an antibiotic and treatment regime.

Your role: You should submit 51701 with 599.0. Listing separate diagnoses shows the payer that the physician didn't have a final diagnosis at the E/M service's conclusion. Thus, your coding justifies that the office visit led to the decision for surgery (i.e., the catheterization), and is separately identifiable from the catheterization and, therefore, deserves reimbursement.