Coding Cues: Answers to your questions about...

September 21, 2007

Monitoring patients; care-plan oversight; ABNs

Key Points

Monitoring patients

I'm an FP who's struggling to keep my practice operating profitably. I thought of some things I do that I'm not paid for, like monitoring a patient after an allergy injection or explaining test results during a subsequent visit. Can I get reimbursed for these services?

That depends. Monitoring a patient after an allergy injection is part of the injection administration service and is included in the reimbursement for that procedure. But if the patient has an adverse reaction and you need to treat her, you could submit an E&M service code appropriate to the level of care you provide and attach modifier –25 (significant separately identifiable evaluation and management service . . .).

Care-plan oversight

I have a number of non-Medicare patients in nursing homes, whose nurses call me often with questions. My billing staff has told me that we can't get reimbursed for telephone calls, even though there are CPT codes for them. Is that true?

Pretty much. In general, phone calls to nursing homes aren't reimbursable individually, but may be reimbursable as part of care-plan oversight services. The time you spend in each encounter by phone should be documented in the patient's chart, totaled, and billed monthly as part of the care-plan oversight services using either 99374 (physician supervision of a patient under care of home health agency . . . 15-29 minutes) or 99375 ( . . . 30 minutes or more). Your payment will depend on the insurers' policies.

ABNs

We know it's necessary to give a patient an Advance Beneficiary Notice for a service Medicare doesn't cover, but our problem is that we don't always know which services will be denied and for what reason. Is there a list somewhere of CPT codes that Medicare won't cover?

No. Medicare coverage is based upon medical necessity, so the same CPT code may be a covered service when you use one diagnosis and a noncovered service when you use another.

Check the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) at your carrier's website. Services are listed there by CPT code, along with medically necessary diagnosis codes. If a diagnosis isn't on the list, then it isn't covered for that service, and a patient who has that condition should get an ABN. For your services that aren't on the NCD or LCD lists, check your Remittance Advice notices. Note the reason for the rejection and document the diagnosis used. Working with these sources, you should be able to develop a comprehensive list of the services requiring an ABN and the reasons why they weren't covered. Remember, ABNs aren't required for services that Medicare never covers.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.