Phone calls; Patient fearing STDs; Two providers, one lesion
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Q: Although I sometimes spend a lot of time managing patients over the phone, I don't use telephone codes 99371-73 because Medicare and most private payers don't reimburse for them. Some insurance companies, however, do pay for the phone codes. Is it fraudulent to bill these codes only to the patients' insurance companies that I know will reimburse them, or should I bill all patients alike regardless of carrier?
A: Billing the phone codes (99371-73, telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals) to some insurance companies and not others is perfectly legal. But if you use this method, and the insurance company denies the claim, you are obligated to bill the patient. To bill the insurance company and not the patient is considered fraudulent. If an audit reveals that you didn't attempt to collect from the patient after a denial, you could face financial penalties or be kicked out of the insurance plan.
Don't bill the telephone codes to Medicare, though, because it considers them bundled. Some private payers follow Medicare's lead and bundle the codes as well. Practices don't always know in advance whether the carrier bundles them, so if you accidentally bill them to such a payer, do not, in turn, charge the patient after the denial.
You should also consider the public relations issue. Because you will sometimes be billing patients instead of insurance, you must always weigh the effect it may have on your reputation in the community. If no other practices are doing it, charging patients for phone calls can harm the image of your practice.
If you spend a lot of time managing patients on the telephone, negotiate a reimbursement policy with your insurance companies during the next contract negotiation. When you bill phone codes, make sure to document the call in detail.
Following these basic rules of phone codes will increase your chances of reimbursement:
Don't bill phone codes when the patient calls in; only when you call the patient.
Don't use telephone codes when a nurse or physician assistant calls a patient.
Don't use the telephone codes when calling in a prescription.
Don't include phone time in the next office visit. When coding on the basis of time, the time included in the E&M visit must be face-to-face time only. If the physician documented the phone call, the conversation can become part of the history in the documentation of the E&M visit, but it is not likely to change the level of service.
Q:A healthy patient came to our clinic with no complaint or symptom but in great fear that she might have a sexually transmitted disease (STD). She asked to be tested. I did the test, which was sent to the lab, and then talked to her for about 10 minutes. Should this be billed as a consult or an office visit? What diagnosis should I use to bill the insurance? If the test is negative, which diagnosis code should I use?
A: Code the patient's encounter as an office/outpatient visit, using the chart documentation to determine if the visit meets the criteria for billing a 99212 or higher-level code. The visit does not qualify as an office/outpatient consultation (99241-45), because a consultation must be requested by another physician or appropriate source (generally a health care provider). You also can't code the visit as a confirmatory consultation (99271-75), the only consultation that can be requested by a patient, because the confirmatory consultation is a second opinion.
Code the diagnosis with V01.6 (contact with or exposure to venereal diseases) if the patient had an encounter with someone who had a known disease. If the patient is simply concerned that she might have an STD, use V71.89 (observation for other specified suspected conditions).
The lab tests are coded using the special screening for disease categories (V73.0-V75.9) with actual codes used dependent on the types of diseases tested. This diagnosis will not change, even if the test returns positive. Your diagnosis for a test on an asymptomatic patient is always the screening diagnosis, because your primary diagnosis must be the reason the test was performed. You can code a more definitive diagnosis after the test has been performed only when the patient presented with signs or symptoms.
Q:We performed an I&D on a sebaceous cyst and used CPT code 10060. This code has a 10-day postoperative period. But the patient had to return every two days to have the site repacked, for a total of five postprocedure visits. Are these five visits included in the global? Should we have used a different code?
A: Most carriers do consider these visits part of the global package. Although CPT's definition of the global surgical package does not include visits to treat complications resulting from a minor surgical procedure, most payers follow Medicare'snot CPT'sglobal surgical package guidelines. Medicare states that all visits related to the surgical procedure are covered during the global period.
CPT 10060* (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) sounds like the appropriate code based on your brief description of the procedure. You would select another code only if it more accurately describes the procedure performed, not because it has a different global period.
Q:Two providers (one an MD, the other a nurse practitioner) worked together to remove a patient's lesion. Because the NP usually does not do stitches, the doctor was there to instruct him. Which provider should we bill under?
A: It appears that the NP performed most of the work, removing the lesion and then stitching the wound under the doctor's guidance. You could file the claim for 11403 (excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 2.1 to 3.0 cm) two ways, depending on payer policies.
For maximum reimbursement, file as an "incident-to" claim under the physician's provider identification number (PIN). Medicare defines incident-to as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness. Although the physician is present in the examining room in this case, he doesn't have to be in the room with the NPjust somewhere in the officefor an incident-to claim to be filed. The incident-to claim is filed as if the doctor performed the service, and reimbursement is 100 percent of the Physician Fee Schedule.
Your other alternative is to file under the nurse practitioner's PIN if the payer recognizes the services of nonphysician practitioners. Medicare and most Medicaid plans recognize NPs and other nonphysician practitioners, while many commercial payers do not. Reimbursement will be less, however. When you file the claim under the NP's PIN, reimbursement is 85 percent of the Physician Fee Schedule.
This information 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 Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.
Coding Consult: Answers to your questions about. . .. Medical Economics 2002;22:16.