Primary Care Coding Alert

IPPE, AWV, and E/M key opportunities for education.

The need for fall risk prevention counseling for our elderly population is pretty evident.

Stats: The National Council on Aging (NCOA) estimates that in 2010 alone “over 20,000 people 65 and older died from injuries related to unintentional falls [and] about 2.3 million people 65 and older were treated in emergency departments for nonfatal injuries from falls” (Source: www.ncoa.org/wp-content/uploads/Falls-Prevention-Coalition-Toolkit.pdf).

But as there are no specific fall prevention counseling codes, and some complex guidelines for coding related diagnoses, coding fall risk prevention presents its own set of challenges. So, we brought in a couple of experts to address the most frequently asked questions from coders when documenting fall risk counseling services.

What CPT^® Codes Can I Use for Fall Risk Prevention Counseling?

Your provider can initiate fall prevention counseling in several ways. “Even though there are no specific codes solely for fall risk prevention counseling, for Medicare it would be part of G0402 [Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment] or IPPE,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin. This Welcome to Medicare physical exam is a particularly suitable service as a major component is a balance and fall risk assessment using a tool such as the Tinetti Balance and Gait Evaluation.

“Providers can also incorporate fall risk prevention into another Medicare service, G0438 [Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit] or G0439 [Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit] or AWV,” Rasmussen continues, “or a preventive medicine service such as 99387/99397 [Initial/Periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual … 65 years and older].” Again, these services are ideally suited to counseling patients regarding falls, as risk-factor reduction interventions are integral to preventive medicine visits.

“Fall risk counseling can also be a part of an evaluation and management [E/M] visit such as 99201-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …],” Rasmussen adds. If the counseling is related to the reason for the visit (e.g. the patient presents as a result of experiencing a fall), then it is part of the counseling/coordination of care inherent to the visit, and only the E/M service is reported. If the provider spends more than 50 percent of the visit counseling the patient (e.g. on reducing the patient’s risk for falls), then you could report the level of service based on the time involved.

If your physician provides fall risk counseling as a preventive, risk-factor reduction intervention at a problem-oriented E/M visit, you can also consider reporting the counseling with the appropriate preventive medicine counseling code from 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual …), based on the amount of time spent counseling, in addition to the problem-oriented E/M code.

For example, the patient may see your provider for issues related to diabetes. If the physician takes advantage of the encounter to also counsel the patient on fall risk, you can report the preventive counseling from the problem-oriented E/M by appending 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) to the problem-oriented E/M code to indicate it was a significant, separately identifiable service from the preventive medicine counseling.

What Dx Codes Can I Use?

If your provider documents that the patient has fallen, there are a number of ICD-10 codes that you will need to have at your fingertips. “The first place to turn to would be the R26 (Abnormalities of gait and mobility) series,” Rasmussen suggests.

Your provider may also report a more specific diagnosis, such as H81.0- (Ménière’s disease), also known as vertigo, M62.81 (Muscle weakness (generalized)), or I95.1 (Orthostatic hypotension), which is a condition where a patient’s blood pressure suddenly drops upon standing up from a lying or sitting position, resulting in dizziness or fainting.

“Additionally, you should make sure the provider documents an accurate description of the injury and the circumstances of the fall, such as E884.2 [ Accidental fall from chair] and Y92.001 [Dining room of unspecified non-institutional (private) residence as the place of occurrence of the external cause],” Rasmussen suggests.

“Remember that these are secondary codes and the injury must be coded first,” Rasmussen notes. “However, providing secondary codes on the claim may speed up payment, as some payers will hold claims for an ‘injury’ diagnosis to determine if there is liability outside of health insurance,” Rasmussen concludes.  

And you may need to document encounter codes such as Z01.01 (Encounter for examination of eyes and vision with abnormal findings) if the patient’s falling is due to vision problems, or Z91.81 (History of falling) if the provider has recorded multiple episodes of falling in the patient’s past.

What Other Codes Should I Use?

“Fall prevention is a quality measure, which is typically performed in addition to an E/M service, annual wellness, IPPE, or preventive medicine visit,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. You can capture them using one of the following:

• 1100F — Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER)
• 1101F — Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER)
• 3288F — Falls risk assessment documented (GER).

As these are Category II codes, they are used for tracking purposes and are not required for billing purposes. However, if you use them, “you should look for elements in the record which would support the patient having a relevant history of falls,” Charles concludes.