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Code it right: Get paid the first time


How to avoid coding problems and ensure you earn what you're due

“I became a doctor to help people, not to fill out paperwork.” While that is a common-if understandable-complaint when it comes to coding for medical services, it is also counterproductive. If your practice accepts insurance, whether public or private, coding is unavoidable.

Even if you don’t code yourself, you need to provide the proper documentation for your practice’s coder(s) to bill patient visits correctly.  

With that in mind, we present advice from the experts on how best to approach coding and documentation and make them a part of your daily routine-while ensuring your practice is paid for all the services it provides.

Level of care coding

Bill Dacey, CPC, MBA, MHA, principal of the Dacey Group, has been involved in medical coding education for more than 20 years. Dacey says good coding follows the same principles as good writing: it is all about telling the patient’s story.

“You have an introductory paragraph and a conclusion. You tell them what you are going to talk about, you talk about it a little bit, and then you sum it up.” While that may sound simplistic, Dacey says it is the best way to make sure that you have all the necessary elements in your patient note to code to the correct level of care, and get paid the appropriate amount for your services.

He says his best advice to physicians is “to bring an accounting mindset to the [patient] encounter,” meaning that physicians should supplement their clinical focus with a coder’s perspective. He recommends listing and numbering each patient problem in the note, so that the level of problem severity and medical decision making (MDM) involved is abundantly clear. “In other words, how many things am I dealing with here? [Physicians] need to make that very clear in the history of present illness portion…and they need to make it abundantly clear in the assessment and plan portion of the note.”

Related:ICD-10: The key to getting paid

It is vital that physicians flesh out each portion of the patient note. Clearly documenting the components of history, exam, assessment, and plan, should produce sufficient support for the level of service selected for the patient visit. For example, Dacey advises that when documenting the chief complaint, don’t refer to past visits in a generic way, such as “follow up previous visit,” “existing problems,” or “review labs.” Tell the whole story for the visit and give a concise description of the problem or laboratory test. That way an auditor can follow your logic on code selection, if necessary.

A missing or vague chief complaint could trip a claim denial based on incorrect levels of care, notes Renee Dowling, CPC, CPB, a billing and coding consultant with Indianapolis-based VEI Consulting. While often considered part of the HPI, the chief complaint must be clearly defined for each evaluation and management (E&M) code. “We can’t assume … and the insurance company can’t assume either [why the physician is there], so it needs to be [written] very specific and in the patient’s own words,” she says.

Physicians can turn to resources such as the Medicare Learning Network’s Evaluation and Management Services Guide (available at bit.ly/EM-services-guide) for help in selecting the appropriate level of care for a patient visit. But Dacey says it often boils down to the language of risk, “those key words mild, moderate, severe progression, or breadth of management based on the number of issues addressed.”

To assist physicians with the medical decision making aspect of E&M codes, VHG has developed a handy tool for physicians that can be duplicated in any practice: laminated cards with specific scenarios that include certain diagnosis or diagnoses, diagnostics, and the management options for physicians.

“So if the physician is used to these different scenarios, they will know, overall, the medical decision making level,” Dowling says. “Physicians find it incredibly helpful and it can be applied across the board; it isn’t specialty specific.”


NEXT: Chronic care management


Chronic care management

Medicare’s new Chronic Care Management (CCM) program (CPT code 99490) enables physicians to bill monthly for managing patients’ chronic conditions. CCM requires 20 minutes per month of clinical staff time-including non-face-to-face and care coordination services- to bill for the monthly $41.92 payment. Medicare patients with two or more chronic conditions are eligible, but must opt in, and may be required to pay a 20% co-pay unless they have secondary insurance to cover it.

Physicians are required to obtain a signed contract from each patient authorizing them to be the patient’s CCM provider and granting permission to share data with other providers for care coordination purposes, says Nancy Enos, FACMPE, CMPA, principal of Enos Medical Coding in Warwick, Rhode Island. “The patient must consent to have this service. You can’t have a blanket standing order for this service. It has to be medically necessary and agreed to by the beneficiary.”

In order to bill the CCM code practices must provide:

  • continuity of care services;

  • 24/7 access to care management services;

  • a comprehensive patient care plan that includes an assessment of the patient’s medical, functional, and psychosocial needs; preventive care, medication reconciliation, and oversight of the patient’s medication self-management;

  • electronic health record (EHR) capture and sharing of care plan information; and

  • management of care transitions, including referrals and follow-up after hospital discharges and emergency department visits.

The comprehensive care plan must be available to all members of the care team, including physicians in other practices. This requirement is creating headaches for some practices due to the difficulties of sharing data among different electronic health record (EHR) systems. says Betsy Nicoletti, MS, CPC, founder of Codepedia.com, a wiki devoted to physician reimbursement. “I think the EHR issues are the main challenge in terms of how do we document these.”

Related:Chronic care management success

“I think the groups that are most successful [with CCM] are groups that have already implemented PCMH [patient-centered medical home] or have care management in their practice,” Nicoletti adds. “If you’re a small private practice, and you haven’t begun doing PCMH or don’t have a nurse who is managing some of your patients with chronic illness, I would start there. You need to build up the infrastructure.”

Below are considerations on properly providing and billing for CCM services, according to Enos and Nicoletti:

Billing timing CCM services can only be billed at the end of the month, so it’s crucial to track the time spent on patients for whom you meet the 20-minutes-of-services threshold. “If it’s a 30-day period covered by the code, it can’t be billed until the end of that time period. I think sometimes doctors mistakenly put down the code when they see the patient,” Enos says.

Make sure your clinical documentation supports the time spent on each patient and, equally important, the medical necessity of the time spent, which justifies any revisions to the care plan.

Software needs You must have a place in your EHR for documenting management of CCM patients. If your software doesn’t provide a workable solution, look for external software providers with products that can tie in to your EHR. “The practice has to be using a certified EHR, and the care plan has to be available electronically to the patient and other providers,” Nicoletti says. “Anyone whose minutes were counted has to have this electronic access.”

Information exchange Sharing patient care plans with providers in other practices must be done electronically in a way that is secure and HIPAA compliant.

Staffing needs If your practice is not a PCMH or using another care-coordination model, consider hiring or assigning a current member of your clinical staff to work as a care coordinator so as to begin building the infrastructure and workflow you’ll need to bill the CCM code.

Document opt-outs Patients can opt out of CCM services with a physician at any time. So be sure to document when a patient cancels CCM services with you.

These requirements are making it difficult for some physicians to implement CCM in their practices. Kenneth R. Kubitschek, MD, an internist in Asheville, North Carolina, and a member of the Medical Economics editorial advisory board, said his eight-physician practice is eager to begin using CCM, but still needs to iron out some workflow and EHR issues.

“Getting the patient’s consent can require significant education as to the benefits of this service,” Kubitschek says. “Our EHR is not set up to easily document and code segments of time and then combine these disparate entries to insure that the 20 minute minimum for billing has been met.”

Other challenges include managing CCM with transitional care management to ensure they are billed correctly, and persuading patients to pay the necessary copays. The latter, he says, “is no easy task.

“Once we feel that we have an adequate handle on the methodology and billing, we do plan to deploy this service,” he says.


NEXT: Transitional care management


Transitional care management

Transitional care management (TCM) codes were introduced in 2012, but remain either misunderstood or ignored by some physicians. TCM includes CPT codes 99495 and 99496, each requiring a different level of care.

There are real economic and patient-care benefits to instituting TCM in your practice. While Medicare reimbursement rates vary depending on your geographic location, CPT code 99495 generally pays about $164. For the higher-complexity code 99496, Medicare will pay about $231.12.

These codes can be used, to bill time spent coordinating care for patients making the transition from an inpatient hospital or skilled nursing facility back to the patient’s community setting, with the goal of reducing patient re-admissions.

Related:Chronic care management facing uphill battle

Practices must meet three requirements to be eligible to bill the TCM codes:

  • communicate with the patient or a caregiver within two business days of inpatient discharge;

  • conduct a face-to-face visit with the patient within either seven or 14 days of discharge, depending on the level of complexity, and

  • employ medical decision of either moderate or high complexity.

In addition, the rules for the TCM codes permit only one billing per patient in a 30-day patient, which can be billed only on the 30th day following the patient’s discharge. Thus, among the challenges practices face is keeping track of when patients are discharged, so that they can be engaged within two days via non-face-to-face communication and so that the practice knows when to submit bills for TCM services.

“If there is a person in the office who has a clinical operations supervisory role, make it their priority to check hospital patients every day and make sure there’s patients are discharged, and put a tracking mechanism in place,” Enos advises.

“One problem physicians encounter with TCM is that no non-face-to-face care is documented,” she adds. “They forgot there are these other requirements. The bottom line is that if there wasn’t any [non-face-to-face services] provided, then you didn’t meet the requirements.”

An additional challenge, Nicoletti says, is that most EHRs are not set up to allow for documentation. “A lot of our software doesn’t have formats for TCM. It’s hard to get all of the work in one place. Software companies need to develop a template to use for TCM.” The best thing a practice can do to ensure payment when using TCM or any codes is to document everything thoroughly, she says.


NEXT: Combination billing


Combination billing

On Jan. 1, 2011, Medicare implemented the Annual Wellness Visit (AWV), CPT codes G0438 and G0439; a prevention planning service for Medicare beneficiaries. Dacey says that before then, Medicare would not reimburse physicians for both a preventive service and problem management visit provided and billed on the same day - even though Medicare always has encouraged providers to bill for all the services they provide. “[The] CPT and AMA and … Medicare have always said, ‘When you do two things and they are significant things, you should bill two things,’” Dacey says.

Commercial payers were not quite so intractable, Dacey says, but it was the minority that reimbursed physicians for providing both services on the same day. “The commercial payers, 10 years ago, 80% of them did not pay for combination preventive and medical management on the same day,” says Dacey. Now that policy has been reversed, he says, with roughly 80% of payers reimbursing for both services, when documented appropriately and performed on the same day.

Related:What you need to know about chronic care management

So if the path to reimbursement for dual services is open, what are the required components to make sure your practice is paid for all the services it provides? The Medicare transmittal issued at the time of the AWV’s introduction instructs providers to use modifier 25 along with the correct E&M code when performed on the same day as the AWV.

Dacey says the process serves to highlight the importance of thorough and detailed documentation in the patient chart that demonstrates the medical necessity for providing both services on the same day. “You absolutely need to say, ‘Patient is here for the Annual Wellness Visit,’ and don’t say, ‘follow up of chronic medical problems.’ Tell us hypertension, hyperlipidemia, diabetes, [for instance] and then give us the history of present illness that goes with those things.” And back up those diagnoses with test results showing blood pressure readings, the last LDL result, and the blood glucose measurements, he adds.

Not all the work involved in an AWV needs to fall on the physician’s shoulders. The AWV is meant to be a collaborative service, meaning advanced practitioners could be involved with some of the patient assessments and screenings. Also, this type of combination visit is perfectly amenable to the use of templates, provided they are constructed well. Dacey says he consults with many groups that use templates for this type of combination service, and when done well, they are absolutely appropriate.

“… [Physicians] have fantastic templates for these kinds of combination visits,” he says. “They’re great: they cover all the Medicare specific pieces, they cover all of the problem oriented specific pieces, you’ll look at this thing and it is very clearly a combination of two distinct types of services.”


NEXT: Using modifiers


Using modifiers

Dowling says two of the most overused E&M modifiers medical practices use are 25 and 59. Here’s how to use them the right way.

Modifier 25 is added to E&M codes to indicate that a significant, separately identifiable E&M service was provided by the same physician on the same day as a minor surgical procedure. Dowling notes that Medicare has clarified that if the work for the E&M code is more than you would have done preoperatively for the procedure that day, you can bill using modifier 25 in addition to the procedure itself. Furthermore, if you are addressing a different diagnosis than the procedure the patient came in for and if the work you perform is significant, then modifier 25 is justified. Dowling says when she is auditing practices’ charts she looks for two things:

  • Is the modifier being used correctly? (Is there a need for the modifier?)

  • Is the documentation supporting the modifier present?

So if you can’t answer these two questions, you might want to skip using modifier 25, because a payer’s auditor - including CMS- might well ask these same questions. “[Use of modifier 25 is] something that needs to be looked at before it is billed,” Dowling says. “It’s not that the physician is not doing the work, it’s usually that the documentation may not have all those elements to show the extent of the work they are doing.”

Related:Coding changes for 2015: New evaluation and management codes explained

For modifier 59, most commonly used for surgical procedures, nonsurgical therapeutic procedures, or diagnostic procedures distinct or independent from other services performed on the same day, there seems to be some confusion, notes Dowling.

Adding another layer of complexity is the fact that CMS has added four “subsets” of modifier 59, better known as the “X” modifiers, to provide greater specificity. “Some of the X modifiers, I think, are confusing and I don’t think our providers know how to use them appropriately,” says Dowling. Her advice? Use modifier 59 as “the modifier of last resort,” especially if your practice is simply adding modifier 59 to override edits in your coding software and get paid for something payers wouldn’t normally reimburse.

“A claim getting paid doesn’t mean it was billed appropriately, which sets you up for audits in the future,” Dowling says. “If any other modifiers are applicable to a situation in terms of how you are billing, those should be used instead.”


NEXT: Level of care coding and more


Level of care coding: Key components

CPT Code
Presenting problem
Patient history
Medical decision-making


is self-limited or minor; the physician typically spends 10 minutes face-to-face with the patient and/or family
problem focused
problem focused


low to moderate severity; the physician typically spends 20 minutes face-to-face with the patient and/or family
expanded problem focused
expanded problem focused


moderate severity; the physician typically spends 30 minutes face-to-face with the patient and/or family
low complexity


moderate to high severity; the physician typically spends 45 minutes face-to-face with the patient and/or family
moderate complexity

Source: Centers for Medicare and Medicaid Services


How to implement chronic care management (CCM) codes

Identify patients

Physicians can bill for CCM codes for Medicare patients diagnosed with two or more chronic conditions that will last at least a year. The first step, then, is to identify the patients in your practice who qualify. This can be done by searching your EHR records.

Invite patients to participate

Physicians must obtain an eligible patient’s written consent to participate in CCM, along with authorization to share the patient’s records electronically with other providers. The physician should explain how the program works, the patient’s obligations for payment, and how to terminate the arrangement.

Build a care plan

A care plan must be created for each patient that includes an assessment of the patient’s medical, functional, and psychosocial needs, consistent with the patient’s choices and values.


All of the above information, from patient consent through the care plan, must be documented in the patient’s electronic health record. When in doubt, document it.

Termination considerations

Patients can only participate in CCM with one primary care provider, and they can opt out at any time. Physicians must document patients who cancel CCM services.


TCM considerations

  • Medication reconciliation and management should occur no later than the face-to-face visit.

  • The codes can be used following discharge from an inpatient hospital setting.

  • The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) because the services are considered duplicative.

  • Billing should occur at the conclusion of the 30-day post discharge period.

  • The TCM codes are payable only once per patient in the 30 days following discharge, so if the patient is readmitted TCM cannot be billed again.

  • Only one individual can bill per patient, so it is important to establish the primary physician in charge of care coordination during this time period. If there is a question, contact other physicians providing care to the patient to clarify. The discharging physician should tell the patient which clinician will be providing and billing for the TCM services.

  • The codes apply to both new and established patients.

Source: American College of Physicians


NEXT: Coding opportunities


Coding opportunities

You are likely talking to your patients about the need to stop smoking - so why not get paid for it?

Coding expert Renee Dowling, CPC, CPB, says four codes are available for tobacco counseling for patients who make two cessation attempts in a year:

  • G0436 and G0437 for Medicare patients who use tobacco but are asymptomatic from the tobacco use; and 

  • 99406 and 99407 for any patient with symptoms from tobacco use.

Kenneth Kubitschek, MD, notes that some of his Medicare patients do inquire about the charge. “I explain that tobacco cessation counseling is a quality metric by which I am being evaluated and that these codes demonstrate quality compliance. Finally, I explain that I would be more than happy to stop billing for this service if they will just stop smoking.”

Whether part of an initial Medicare Annual Wellness Visit or other annual visit, physicians have at least one opportunity to bill for depression screening of 15 minutes or more under G0444 , which CMS defines as, “at a minimum, staff-assisted depression care supports consist of clinical staff (e.g., nurse, physician assistant) in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals for necessary mental health treatment.”

“Our primary care providers are handling those types of behavior challenges with patients much more … as there is a much wider understanding of the challenges of anxiety and depression, “Dowling says. “And I think patients don’t have the time to go to a specialist for it, and they take the time with their primary care physician to do [the screening]. I think a lot of our PCPs are managing that.”

The annual Medicare wellness exam ( G0438 ) and first-year preventative physical ( G0402 ) are two services that physicians sometimes don’t take advantage of as much as they should, says Nancy Enos, FACMPE, CMPA, principal of Enos Medical Coding in Warwick, Rhode Island.

The first-year exam, available to Medicare beneficiaries within their first year of enrollment with the program, can be tricky since each patient is only eligible for one from one physician.

But it’s doable, Enos says. Practices should run a list of patients who are within their first 6 months of Medicare enrollment, using data within their practice management system. This provides a good list for outreach.

Modifier 59 subset codes

Modifier XE -Separate Encounter

  • A service that is distinct because it occurred during a separate encounter.

Modifier XS -Separate Structure

  • A service that is distinct because it was performed on a separate organ/structure.

Modifier XP -Separate Practitioner

  • A service that is distinct because it was performed by a different practitioner.

Modifier XU -Unusual Non-Overlapping Service

  • A service that is distinct because it does not overlap usual components of the main service.

Source: Renee Dowling

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