Primary Care Coding Alert

Separate chart notes and diagnoses justify office visit reimbursement

You can overturn denials for an office visit 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) is no longer a "starred procedure," payers now include minor pre-, intra-, and post-E/M services 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 FPdocuments an E/M service beyond what the scheduled catheterization includes.

But insurers may still bundle 9921x into 51701. The solution: Provide iron-clad documentation with diagnoses that justify your office visit payment.

1. Include 3 E/M Findings in the 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 your FPincludes an initial assessment and plan in the office note. You can then use the preprocedure diagnosis with the office visit to show the payer that the E/M service led to your FP's decision.

Example: A 9-month-old girl presents with fever and symptoms that suggest a urinary tract infection (URI). 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.

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) to the office visit code. "This tells the payer that the FP performed a separately identifiable service from the catheterization," says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine FPs, in Escondido, Calif.

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 operative 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, is separately identifiable from the catheterization and, therefore, deserves reimbursement.