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Coding Consult: Answers to your questions about. . .


DRE payment; When a patient needs oxygen; Coding an admission that goes bad


Coding Consult

Answers to your questions about . . .

• DREs are reimbursed only once a year.  

• No code exists for office 02 administration.

• You can code both 99223 and 99291 on the same day.

DRE payment

Q: I know G0102 (prostate cancer screening; digital rectal examination) is covered, but when we bill it with an E&M service and modifier –25, we're denied. They say it's bundled with the E&M visit. Medicare says it will reimburse G0102 if it's the only reason a patient presents, but I can't imagine a patient coming in specifically for a DRE. How can I get paid?

A: Medicare covers prostate screening tests and procedures for the early detection of prostate cancer—DRE (G0102) and the prostate specific antigen test (G0103). If the DRE is the only service, or is provided as part of an otherwise noncovered service, such as a preventive medicine visit (99397), HCPCS code G0102 would be payable separately if all other coverage requirements are met. (The basic standard for billing a G0102: you must perform the DRE on a male Medicare beneficiary over age 50, and only once every 12 months.)

Per Medicare guidelines, billing and payment for G0102 should be bundled into the payment for a covered E&M service when the two services are furnished to a patient on the same day. Use diagnosis code V76.44 (special screening for malignant neoplasms, prostate).

When a patient needs O2

Q: A patient suffered syncope and collapsed in the office. We administered oxygen and cared for her until the paramedics arrived. How should we code for oxygen administration in the office? What other codes should we use?

A: There's no code for oxygen administration. The service is included in the E&M service, so bill the appropriate level of E&M.

Depending on the services provided, the patient's condition, and how long it took the paramedics to arrive, you'll most likely bill an office visit code (99201-99215). For you to use a critical care E&M code, the patient must meet the definition of "critically ill or injured" as defined in the CPT guidelines. In addition, you must spend at least 30 minutes face to face with the patient prior to the paramedics' taking over care.

Coding an admission that goes bad

Q: A patient is admitted for chest pain. He later takes a turn for the worse and is moved to the ICU. I'm called back. Should I bill for an admission and critical care services on the same day by the same doctor? If I use both 99223 and 99291, do I need a modifier?

A: Yes, to both questions. You can use the code for initial hospital admission, 99223, and then code the critical services later in the day with 99291 (critical care, E&M of the critically ill or critically injured patient; first 30-74 minutes) and 99292 ( . . . each additional 30 minutes) if the encounters meet the criteria for those codes.

The situation you describe is covered in the Medicare Carriers Manual. It says, in Section 15508(F), that "if there is a hospital or office/outpatient E&M service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the E&M service may be paid."

To use those codes, though, you must provide critical care services for at least 30 minutes during the second encounter and document that in the medical record. Append modifier –25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to the critical care code (99291), and provide documentation supporting your use of two E&M codes on the same day.


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 Road 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 Apr. 25, 2003;80:19.

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