Primary Care Coding Alert

Additionally, guideline I.C.21.c.17 explains that “Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.”

In summary: Even though MAs are qualified to provide a lot of the basic care — such as performing phlebotomies, taking vital signs, dressing wounds, updating records, and even educating patients on a variety of health issues — they cannot document the patient’s symptoms, which are not included in the above.

Note: BMI, specifically, is something that you should be careful of regardless. “Many electronic medical records [EMRs] will now provide the calculation [of BMI] if the patient’s height and weight are documented. But I would not recommend assigning a BMI code if the BMI was not documented,” notes JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. As ICD-10 Guideline 1.C.21.c.3 states, “BMI codes should only be assigned when there is an associated reportable diagnosis (such as obesity)” (emphasis retained).

Myth 2: Physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs) cannot supervise pulmonary rehabilitation and cardiac rehabilitation services.

This is false, because effective Jan. 1, 2024, CMS is allowing nonphysician practitioners to supervise pulmonary rehabilitation and cardiac rehabilitation services. According to the 2024 MPFS final rule, “nonphysician practitioners” are defined as PAs, NPs, and CNSs, so they may now supervise those services.

The supervising physician or nonphysician practitioner must be always available while the pulmonary or cardiac rehabilitation services are being rendered in case of emergencies or for medical consultations.

These services still come with a few strict requirements, however. For instance, according to the Medicare Claims Processing Manual, section 140.4.1, healthcare providers may report up to two 1-hour pulmonary rehabilitation sessions per day (www.cms.gov/ regulations-and-guidance/guidance/manuals/downloads/clm104c32.pdf). The documented time spent providing treatment must pass the halfway mark of the first hour to receive reimbursement. This means the provider must document at least 31 minutes of treatment to report one hour of pulmonary rehabilitation service.

At the same time, the documentation must include at least 91 minutes of treatment time to meet the threshold for reporting two pulmonary rehabilitation sessions on a given day (60 minutes for the first session +31 minutes for the second session).

Additionally, a provider must furnish pulmonary rehabilitation services in either a physician’s office (Place of Service (POS) code 11) or a hospital outpatient setting (POS 22). Medicare contractors will deny all other POS codes.

Myth 3: For lab tests such as urinalysis tests performed in the office for which a nurse researches the history, collects the sample, then gets the results, you should bill 99211 with the appropriate code.

Whether this is a myth or not depends on a few things. There are no CPT® guidelines to prohibit you from reporting 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) with a urinalysis code such as 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) in the outpatient setting. Likewise, no National Correct Coding Initiative (NCCI) edit exists for 81000-81003 (Urinalysis…) when the tests are Column 2, or component, codes for office/outpatient E/M services 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …).

That being said, when reporting 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), there must be some “evaluation and management” of the patient. Obtaining patient history and getting lab results doesn’t generally rise to the level of evaluating and managing the patient. Billing an evaluation and management (E/M) service in addition to a lab test, such as a urinalysis, requires that work over and above the lab test (e.g., patient exam, implementation of treatment plan) needs to be done. Looking at patient history, collecting the sample, and getting the lab results would typically be part of the work associated with the lab test, rather than work over and above that test.

If there is a truly separate E/M service, most of the time the work associated with the E/M will rise above the level of 99211, and the order for the test is often the result of an E/M service.

Although not required by NCCI edits, when urinalysis is separately reported in addition to an E/M, some payers may require a 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] be appended to the E/M.

In cases where payers deny 81000-81003 as bundled into an office/ outpatient E/M, you can also try appending modifier 59 (Distinct procedural service) to the 81000-81003 codes to see if that overrides the edit in question.

Coding alert: Don’t forget that 99211 typically exists as an incident-to code and represents a service the physician has delegated to a nurse. In Medicare parlance, the service is “furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.” If the physician does not see the patient and the nurse provides the service pursuant to a plan previously established by the physician (i.e., not a new patient or new problem), you can generally bill 99211 under the physician’s credentials. If the physician does end up seeing the patient, then the physician would probably end up billing something higher than 99211, such as a 99212, assuming the physician’s documentation supports that.