Coding evaluation of medications, Two office visits on one day, Billing for a normal BP check
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Q: Under which key component should I account for review of a patient's medication list during an E&M visit?
A: This activity counts as one element of the past history review. According to CPT, past history includes the patient's past experiences with illnesses, operations, injuries, and treatments.
Q:Early one morning, I diagnosed a woman with acute bronchitis and hypertension, gave her a bronchodilator, and sent her home. She returned later that day with elevated blood pressure (higher than the morning visit) and a headache. I determined that her symptoms were probably a reaction to the bronchodilator. After she rested for an hour in the office, her headache subsided and her blood pressure went down. Because the two visits were extensive, I want to bill for both. Will the claim be denied for billing two office visits in one day?
A: No. It's a common misconception that you can't bill for two office visits in one day. While you can't bill for more than one hospital visit per daybecause the visit codes are per-diemthat doesn't apply to office visits. Bill for both office visits with the appropriate-level E&M code and append modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the second visit.
You don't need a different diagnosis for the second visit because you're attaching modifier 25. This modifier permits the second E&M service to be prompted by the symptom or condition that caused the first visit. Link the diagnosis codes for acute bronchitis (466.0) and hypertension (e.g., 401.1, essential hypertension, benign) to both E&M codes.
Q:How should I code if a patient comes in for blood pressure monitoring only and the BP is within normal range? I didn't perform an exam or take a history.
A: Use 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician . . . ) for the office visit. Unlike other office visit codes, 99211 doesn't require you to take a history or perform an exam; documentation guidelines require only a chief complaint. Further, you can bill 99211 if a nurse takes the BP, as is the protocol in many primary care practices. You'd still have to sign the patient's chart, though.
If the patient is coming in for a screening, use V81.1 (special screening for cardiovascular, respiratory, and genitourinary diseases; hypertension). Medicare will not reimburse the BP check in this case, so you will need to either charge the patient (assuming she has signed an advance beneficiary notice beforehand) or provide the BP check for free, as many practices do.
If the patient has been diagnosed with hypertension and is returning for follow-up to check on his or her chronic condition, most payers will consider the BP check medically necessary. You should bill 99211 with 401.1 (essential hypertension, benign).
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;18:14.