CODING Q&A Readers’ Coding Inquiries ■ DAVID STERN, MD, CPC Q . How would you define the difference between an expanded problem-focused exam and the de- tailed exam in the 1995 evaluation and management coding guidelines? – Question submitted by Eddie Stahl, Medical Staff Director, Tennessee Urgent Care Associates For both the expanded problem-focused exam (EPF) and the detailed exam, the provider must document between two and seven body systems. The difference is that the EPF exam requires a “limited” exam of a body area, but the detailed exam requires an “extended“ exam of a body area. The difference between the limited and extended exams has never been clearly spelled out by the Centers for Medicare & Medicaid Services (CMS), so it has been left to the coder or auditor to determine whether the exam is “limited” or “extended.” As with beauty, the difference is simply in the eye of the beholder. Of course, this ambiguity has left many coders frustrated with the 1995 guidelines. That is the main reason that CMS came up with the 1997 guidelines. But the 1997 guidelines were too rigid for realistic application to real-world clinical encoun- ters, so CMS has simply allowed providers to use whichever set of guidelines they feel most comfortable using. A. Q . We do not receive adequate reimbursement for B-12 injections. Can we charge out a 99211 along with the administration charge and B-12 charge? – Question submitted by Tammy Higgins, Physicians Care, Chattanooga, TN To use 99211 properly, the chart will need to demon- strate clearly that the nurse did an evaluation and management of the patient’s condition. I have previously A. David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m written fairly extensively on the criteria for using 99211 (see Coding Q&A, JUCM, April 2007). If you are not being reimbursed (i.e., are getting payment denials) for many of the B-12 injections, you may need to look at the ICD-9 that you are using with the injection code. Many payors (including Medicare) limit reimbursement to ICD-9 codes for specific conditions related to B-12 deficiency, such as pernicious anemia and dementias secondary to vitamin B- 12 deficiency. Q . We bill for four clinics that are licensed as “outpa- tient clinics.” We are confused on the place-of-serv- ice code because place-of-service 22 states the facility is part of the hospital, but the urgent care seems more appro- priate. However, we were told it was not appropriate be- cause it must be provider-based and the doctor-owned facility doesn’t bill separately for the facility charge. We only bill the professional charge for our doctors. – Question submitted by Tammy A. Lovely, CMRS, Director of Coding, Apollo Information Services, Inc. No matter what your location (hospital, freestand- ing, in multispecialty clinic, etc.) or billing structure (facility only, provider only, combination) every payor is likely to see the place-of-service issue differently. There is no hard-and-fast rule for any given payor. You may minimize denials by using the place of service - 22 (Outpatient Hospital), but it is always best to check with each individual payor. Of course, most of us hate that “check with your payor” phrase because so often the payor repre- sentative does not know the answer—or, even worse, gives us the wrong answer. A. Q . We have a radiologist read every x-ray study that we do. How should we code for this? – Question submitted by Giridhar C. Kamath, DO, Surya Immediate Medical Care, Latham, NY Physicians may use one of three coding methods in this situation. Your radiologists may have a strong preference for one or the other. A. Continued on page 36. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | M a r c h 2 0 0 8 35