Coding Consult

September 16, 2005

Answers to your questions about...bone density studies; ABPM coverage; prolonged office visits

Bone density studies

Q What are Medicare's requirements for reimbursing bone density studies?

To avoid having a claim denied, make sure that you, the consulting physician, or a qualified non-physician practitioner provides an order for the bone density study.

Tests are covered every two years, but if medically necessary, Medicare may provide coverage more frequently.

ABPM coverage

Q I've started providing 24-hour blood pressure monitoring. How should I report this service?

A Medicare will reimburse for ambulatory blood pressure monitoring (ABPM) only when you use it to test for white-coat hypertension. You'd use one of the following codes:

In the case you described, your primary ICD-9-CM code should be 796.2 (elevated blood pressure reading without diagnosis of hypertension).

Private carriers may have more-lenient guidelines, so check with your commercial insurers regarding acceptable diagnosis codes.

Prolonged office visits

Q I saw a Medicare patient with a complicated history in the office for 100 minutes. Based on my documentation, I can report 99215, but this code represents only a 40-minute visit. Should I attach modifier –21 for the additional 60 minutes, or should I use prolonged service code 99354?

A Your best bet is to report prolonged service add-on code 99354 along with 99215.

Be sure your documentation supports using 99354. This code requires face-to-face patient contact "that is beyond the usual service in either the inpatient or outpatient setting," according to CPT. The documentation should include the total amount of face-to-face time spent with the patient.

According to CPT guidelines, modifier –21 (prolonged evaluation and management services) should be used only for the "highest level of evaluation and management service." But Medicare payers typically don't pay extra for this modifier; they use it for informational purposes only.

This information adapted from material provided by the Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact the Coding Institute, 2272 Airport Road South, Naples FL 34112; phone 800-508-2582; fax 800-508-2592 or visit http://www.codinginstitute.com.