Patient came in stating reason for visit "consultation reagrding genetic testing" she has a strong family history of colorectal cancer. The MD is scheduling a screening colonoscopy which under normal cicumstances not allow us to bill an E/M per AGA guidance. However, he did spend 20 minutes counseling her on having genetic testing for lynch syndrome (HNPCC). Would this discussion be billable under 99401 if documented accurately? I am thiking no since the code specifies risk factor reduction which you cannot do for genetics. Help, having self doubts.....
If no, could we have the pateint sign an ABN stating time with teh physician to discuss this is a non-covered service and bill her directly? I hate to give 20 min of MD time away when the pateint just wants to pick his brain.
Anna Barnes, CPC, CEMC
I'm not familiar with the rule you're referencing - you wouldn't be allowed to be reimbursed for an E/M prior to a screening colonoscopy, simply because the decision was made to do the screening at that encounter? I could understand not being reimbursed for an E/M the day of the screening (or the pre-op exam at a prior visit), but the visit wasn't entirely routine. Is he the one doing the colonoscopy? If I'm not mistaken, he had to take her history, evaluate her, and then make a decision to perform a screening based on identified risk factors (it seems as though the decision for surgery visit should be covered). If she's a Medicare patient (which I assume she is, by the fact that you mentioned an ABN), then you'd have to meet certain criteria to satisfy the requirements to report an AWV code, but if her insurer is a commercial payer, then in my opinion, you should have sufficient justification to report an E/M in this situation.
Did she have any complaints (signs/symptoms) to accompany her concern, or was she just worried because of her family history? Did he perform a physical exam, or was the visit predominately based on gathering history and counseling? If she reported signs/symptoms and he performed even a
basic PE, then you may be able to report a problem-oriented E/M and select a level based on time, although it's hard to say without seeing the documentation.
Absent any complaints or exam, I'd say that the counseling you're describing would certainly fit the definition of 99401-99404, but I wouldn't limit the code selection to the amount of time spent discussing the HNPCC, only - deciding to perform a screening colonoscopy sounds like only a small portion of the visit. All of the time that the physician spent in evaluating/counseling the patient on her history and identified risk factors for genetic/cancer problems should be taken into consideration; he did the work, he should get paid for it.
As for whether or not an ABN is appropriate, my best advice is to contact the payer and ask them directly if the service you intend to report is covered. The problem that you may run into, is that an ABN is intended for use prior to
rendering services - meaning that you have to warn them that the visit might not be covered before they receive the service, so that they can decide whether or not to proceed. You can't do the service,
then inform them that it might not be paid, and expect them to accept responsibility for it after the fact - it defeats the purpose of using an ABN in the first place. If this is a Medicare patient and the service you decide to report is not payable, then I'm afraid you'll be forced to write off the charge.
If the patient's not a Medicare beneficiary, then you've got nothing to worry about - just submit the claim for the services rendered, and if it denies, then you should be able to bill the patient. ABN's don't apply outside of Medicare, so whether or not you got one is a moot point for commercial payers. Hope that helps!
