Wiki Guidance needed for coding scenario

[HeatherrLaw]

I started a new job as a medical coder for a practice that sees walk in patients. I am reviewing notes and prepping claims for billers and noticing the provider is entering the following:
Diagnosis : J06.9, R05.9 and R09.81

CPT: 99212(E/M) , 87426 (COVID test) , 87804 (Flu test)

My questions:
In other discussions and the E/M calculator this could be 99213 using the two tests results reviewed in office visit and using the ordering of the tests as separate and that is why all those CPT codes can be used on the claim, correct?

This is a typical scenario for this provider during walk in days and I would like to find out if i am way off and the test cpts should not be added because they are used to determine MDM for the E/M or if they can be added because only the results portion is the points used towards MDM and the ordering is separate.

At this point I have seen so many of them and read so many I think I am confusing myself so I would like some straightforward guidance on whether or not these claims are being coded correctly or what should be done.

 

[csperoni]

Here was my response to your very similar question on another thread:
I think you may be confusing 2 different guidelines.
1) If you perform a service that has a PROFESSIONAL component you bill for, you may not count that test toward your data element for E&M. You would still bill for the test you performed.
2) These labs are results only (NO professional component), so you may count them toward your data element for E&M
From AMA:
►The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.◄

 

[HeatherrLaw]

Here was my response to your very similar question on another thread:
I think you may be confusing 2 different guidelines.
1) If you perform a service that has a PROFESSIONAL component you bill for, you may not count that test toward your data element for E&M. You would still bill for the test you performed.
2) These labs are results only (NO professional component), so you may count them toward your data element for E&M
From AMA:
►The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.◄

Thank you. I apologize if my questions are numerous and repetitive. I was doing billing for several years, just took on a big coding position and am probably overthinking the scenarios. Sometimes it helps to ask questions and get a very basic 'dumbed down" answer to help cut through the misinterpretation. I was just looking for reassurance that billing all those test codes along with the E/M was justified. I will take time to review the information you shared and work from there. Thank you again.

 

[TThivierge]

I started a new job as a medical coder for a practice that sees walk in patients. I am reviewing notes and prepping claims for billers and noticing the provider is entering the following:
Diagnosis : J06.9, R05.9 and R09.81

CPT: 99212(E/M) , 87426 (COVID test) , 87804 (Flu test)

My questions:
In other discussions and the E/M calculator this could be 99213 using the two tests results reviewed in office visit and using the ordering of the tests as separate and that is why all those CPT codes can be used on the claim, correct?

This is a typical scenario for this provider during walk in days and I would like to find out if i am way off and the test cpts should not be added because they are used to determine MDM for the E/M or if they can be added because only the results portion is the points used towards MDM and the ordering is separate.

At this point I have seen so many of them and read so many I think I am confusing myself so I would like some straightforward guidance on whether or not these claims are being coded correctly or what should be done.

Heather
What CSperoni told you is accurate. But let me add on Dx J06.9 it states to add dx B95-B97 as added dx. Now if you are aware of lab result tell you exact bacteria use that dx code too. Positive Covid U07.9 or Flu hope add those dx codes. Influenzas dx range from J09-J11. SARs dx J12.81 Well hope this data helps you
Lady T