Primary Care Coding Alert

Not sure when you should add on another E/M code? Check out these factors to avoid denials. Same Problem Equals the Same Code According to Quinten Buechner, president of ProActive Consultants in Cumberland, Wis., most payers follow Medicare guidelines on claims. Therefore, when considering multiple E/Ms, let the Medicare Claims Processing Manual (MCPM) (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) serve as your most useful guide. Check out these coding rules:

• Physicians who are in a group practice and have the same specialty cannot code separately for their E/M services if they provided those services to the patient on the same day unless the E/M services were for unrelated problems, states MCPM, Chapter 12, Section 30.6.5.

• Since Medicare otherwise considers that E/M services done in this situation are directly related, rather than reporting them separately, you must combine them and report them as if they were one. Use the most appropriate E/M service code to reflect all the work done and documented. Medicare specifies that, "Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level."

Example 1: A new patient comes in the morning to see the family physician with problems of cough and fever. After the doctor examines the patient, the FP diagnoses the patient with pneumonia and gives him medications to take home. The doctor documented spending 10 minutes with the patient.

A few hours later, the patient returns complaining of occasional difficulty in breathing. This time he was seen by another family physician. After examination, the doctor considers adding additional medicines for his  cough but still sticks to the original diagnosis. This time the physician spends another 10 minutes with the patient. To code the two encounters, use the following:

• 9920x -- Office or other outpatient visit for the evaluation and management of a new patient ...

• 482.9 -- Bacterial pneumonia unspecified.

Example 2: An established patient comes early in the afternoon to see his doctor regarding urinary problems. The doctor examines the patient and orders a urinalysis from an outside laboratory.

The patient returns that same afternoon with his test results and is seen by the same doctor. The patient is diagnosed with a urinary tract infection (UTI) by the doctor and given take-home medications. As documented, the doctor spent 15 minutes in total with the patient for the separate visits.

To code these visits, use the following:

• 9921x -- Office or other outpatient visit for the evaluation and management of a established patient ...

• 599.0 -- Urinary tract infection site not specified.

For group practice physicians, Medicare specifies an exemption to the above if the patient is seen for a different case. MCPM, Chapter 12, Section 30.6.7, states, "As for all other E/M services except where specifically noted, carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter." It will also be necessary to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). In addition, according to Connie Stevens, compliance officer and reimbursement manager for Wenatchee Valley Medical Center, "It's not a hard-and-fast rule that you can't bill two visits in one day when you've got appropriate documentation to support why."

The example given in the Medicare Claims Processing Manual is a patient who has an office visit for a blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an  accident.

For another example, the patient comes in the morning for simple chronic bronchitis but later comes back due to accidental injury to the hand. These are two distinct problems in the same day; therefore, use separate E/M codes for this. Here's how:

• 9921x (Office or other outpatient visit for the evaluation and management of an established patient ...)

• 9921x-25 (Office or other outpatient visit for the evaluation and management of an established patient ...)

• 491.0 (Simple chronic bronchitis) appended to the E/M service for the first office visit

• an appropriate diagnosis code reflecting the hand injury (such as 842.10, Sprains and strains of wrist and hand; hand; unspecified site), which will serve as the primary diagnosis for the second office visit

• An appropriate "E" code reflecting the cause of the injury to the hand (for instance, E917.9, Striking against or struck accidentally by objects or persons; other striking against with/without subsequent fall).

Finally, if a patient was seen by a doctor of a different specialty, then a separate E/M should be used for this encounter. As MCPM, Chapter 12, Section 30.6.5, also states, "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group."

For example, if a patient was seen by the FP in the morning for chest pains but was referred to a cardiologist in the group practice for a consultation, then separate E/Ms should be reported as follows:

• 9921x -- Office or other outpatient visit for the evaluation and management of a established patient ...

• 9924x -- Office consultation for a new or established patient ...

• 413.9 -- Other and unspecified angina pectoris (appended to the code for the office visit and to the code for the consultation unless the cardiologist arrived at a more definitive diagnosis).