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Uncompleted procedures? Hereís how to bill
Answers to far-ranging coding questions from readers

Keywords: ICD-9 codes: billing for incomplete procedures, discharge services, and concurrent care


by Tamra McLain, CPC, CPC-H, CMC



Published in the March 2010 issue of Today's Hospitalist

IíVE RECEIVED ANOTHER ASSORTMENT of coding questions from hospitalists and coders, which serves as a nice reminder of just how far-ranging hospitalistsí practices can be. Here are several questionsóand my suggestions on how to handle the billing.

Uncompleted procedures
Q: The hospitalists in our group tried to do procedures on two different patients in the ED. One was a lumbar puncture, and although it was attempted twice, no fluid was retrieved. The other, an effort to remove a foreign body from the external ear, wasnít successful, although the doctor tried several
You need the right modifier to bill both critical care services and an E/M code on the same day.

times using different tools. How should we bill for these?

A: When a procedure isnít completed, bill the CPT code for that service with the -52 modifier (reduced services). That tells the payer that only a portion of the work RVUs was completed, and that full payment may not be warranted. If, however, the physician needed to discontinue the procedure because the patient became unstable, with respiratory distress or tachycardia, for instance, bill the service with the modifier -53 (discontinued procedure).

Incision & drainage
Q: Our physician did incision and drainage of nine total abscesses on the lower extremities on both legs. Should I bill 10061 (incision and drainage of complicated or multiple abscesses) only once because the code covers multiple abscesses? Or can I bill a 10061 nine times and append modifier -59 (distinct procedural service) to eight of them?

A: 10061 specifically refers to multiple abscesses, but most people interpret multiple to mean within a certain area, such as one leg. Iíd suggest billing 10061 twice, with a -59 on the second code. Payers might prefer to see 10061-RT (for right side) and 10061-LT (for left side). Needless to say, be sure to submit the documentation to justify both charges.

Billing for critical care
Q: Weíre having problems billing both critical care codes (99291-99292) and subsequent visit codes (99231-99233) for the same patient on the same day when seen by two providers from the same practice. In the past, we used modifier -77 (repeat procedure by another physician), but we were advised to use modifier -76 (repeat procedure by same physician). Now, instead, all of our claims are being denied.

A: Neither modifier in this instance is correct. To differentiate the critical care service from the regular evaluation and management (E/M) service, use modifier -25 (separately identifiable service on same date) with the E/M service. If you flag them as separate services, you should be paid for both.

Q: How should I bill for critical care services provided from 11:00 p.m.-11:17 p.m. and then again from 11:56 p.m.-12:15 a.m.? According to CMS guidelines, I apparently canít bill for critical care at all because I didnít provide at least 30 minutes of those services on any one day.

A: Thatís sad but true. To bill critical care codes, you must provide more than 30 minutes of those services all on one calendar date. In this case, you would instead bill an initial visit on the first date in the case of a new patient and then a subsequent visit on the second date; or a subsequent visit on both dates, if the patient was established.

Discharge services
Q: When discharging a patient, do I need to state ďdischargeĒ in my note?

A: Itís best to state directly that youíve performed a discharge service (99238-99239) to ensure the service is recognized. For medico-legal reasons, if an attorney or auditor were to examine the chart, you want the record to clearly state that the patient was discharged.

Q: Do I have to document time for a discharge ser vice if Iím billing 99238?

A: 99238 is the lower of two discharge codes, and you donít need to document time spent when billing it. But because the higher discharge codeó99239ósignifies that you spent more than 30 minutes in discharge services, you must note in the chart the amount of time spent when billing that higher code.

Billing initial visits
Q: We have a question on using initial visit codes (99221- 99223) vs. subsequent visit codes (992331-99233). The physician is billing a 99223, but has only an expanded problem, focused history, comprehensive exam and high medical decision- making. Because the lowest E/M in this group, 99221, requires at a minimum a detailed history, some of us think we should bill a subsequent hospital visit instead. What do you suggest?

A: I agree that the subsequent hospital visit code would be more appropriate to use, based on the documentation provided; you canít bill a 99223 with anything less than a detailed history. I have seen both approaches used, billing it either as a low-level initial visit or a higher-level subsequent visitóbut your group needs to choose one as policy and put it in writing.

Concurrent care
Q: How should we bill if a hospitalist and an OB both do an H&P on the same day for the same patient? The OB was the admitting with a direct admission. Can the hospitalist charge a subsequent visit, even though the hospitalistís dictation says history and physical?

A: As the admitting physician, the OB would bill the H&P as part of the initial hospital visit (99221-99223), while the hospitalist would bill a subsequent visit. The hospitalist wouldnít need to dictate a formal note in H&P format, which requires much more documentation than is typical for a subsequent visit.

But even though the hospitalist doesnít need to document an H&P to bill a subsequent visit, this is the hospitalistís first time meeting the patient. For medico-legal reasons, itís probably a good idea for the hospitalist to obtain a detailed history even if you canít bill for an initial visit.

Tamra McLain is client service manager with MedData Inc. E-mail her your documentation and coding questions to tamram@meddata.com. Weíll answer your questions in a future issue of Todayís Hospitalist.
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