Primary Care Coding Alert

Question: A new patient who is unable to communicate clearly and to explain her medical problems came in to see my family physician. Because the FP cannot obtain a complete history of present illness (HPI) and review of systems (ROS), he cannot develop a definite assessment or plan. The FP calls the patient's two previous physicians to understand the patient's medical problems. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, my FP spent 90 minutes on the same day.
How should I charge for this scenario? What E/M codes and modifiers should I use to justify the extra time that my FP spent on the phone with other physicians?

California Subscriber

Answer: You should bill the scenario based on three parts: the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient), additional face-to-face minutes (+99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour; +99355, ... each additional 30 minutes), and indirect service time (+99358, Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; +99359, ... each additional 30 minutes).

Suppose the FP performs a problem-focused history, a problem-focused examination and straightforward medical decision-making. He spends 45 minutes with the patient and 45 minutes talking to other providers. In this case, you should report 99201, 99354 and 99358.

To report the above scenario, first select the E/M service: 99201 (... physicians typically spend 10 minutes face-to-face with the patient and/or family). Next, subtract the E/M service's typical time (10 minutes) from the total face-to-face time (45 minutes), which gives you 35 billable direct prolonged service minutes and qualifies for 99354. For the 45 minutes that the FP spends discussing the patient's problems and management with other providers, you should report 99358.

Although Medicare bundles indirect prolonged services with the E/M service, some private insurers may reimburse for 99358-99359. Even if the payer doesn't cover indirect prolonged services, don't report the telephone call codes (99371-99373, Telephone call by a physician to patient or for consultation or medical management ... with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...), which you shouldn't bill with same-day E/M services, according to CPT Assistant May 2000.