DAVID STERN, MD (Practice Velocity)
Q.Our doctor saw a patient for a sore throat. The rapid strep screen was positive, so she placed the following diagnoses on the chart:

  • 0: Streptococcal sore throat
  • 61: Fever presenting with conditions classi- fied elsewhere
  • 1: Throat pain
  • 79: Other malaise and fatigue

I told her that since we had a specific infection that was the cause of second, third, and fourth diagnoses, we should code the confirmed infection, but not the sore throat. She said that she was addressing each symptom in her plan (for example, acetaminophen for the pain and fever and rest for the malaise), so it was appropriate to code the symptoms as well as the  diagnoses. Who is right?

Question submitted by Jenni Rosenbalm, CPC, PV Billing
A.You are right. In general, the physician should code symptoms when the underlying diagnosis that is causing the symptom has not yet been determined. In your example above, the second diagnosis (780.61: “fever presenting with conditions classified elsewhere”) does seem to be correct at first glance, since strep throat is a “condition classified elsewhere.” When you look at the specific definition of the code, however, this code specifically excludes:

  • [fever as an] effect of heat and light
  • [fever] associated with a confirmed

Rather, this code is for use with conditions that are frequently associated with fever but are not the specific cause of the fever. Often, there is an associated and presumed infection, but there is not yet a specific “confirmed infection.” These conditions “classified elsewhere” include neutropenia, leukemia and sickle-cell disease.

Q.We do x-rays at our urgent care and would like to know if there are different modifiers for the procedures that we do in the office. Could you provide me with a list of modifiers used with x-rays?
Question submitted by Michelle, Defiance Family Physicians
A.Modifiers for x-rays are not unique to the urgent care setting. Commonly used modifiers for x-ray procedures in the urgent care setting include:

  • -R: right—Use this modifier for a film series per- formed on the right side of the
  • -L: left—Use this modifier for a film series performed on the left side of the
  • -TC: technical component—Use this modifier when coding only for performing the technological procedure of taking the x-ray; the physician reading is not in- cluded in the
  • -26: professional component—Use this modifier when coding only for the physician reading; perform- ing the technological procedure of taking the x-ray is not included in the
  • -52: reduced services—Use when performing fewer views than the code stipulates. For example, you use modifier -52 when performing a single-view ankle x-ray and the lowest number of views for an ankle x-ray listed in CPT is for 73600 (radiologic examination, ankle; two views).
  • -76: repeat procedure by same physician—Use this modifier when you perform the same film series on the same Examples include films retaken after fracture reduction, after foreign body removal, etc.

Q.I have a question about a Medicare patient. The patient’s daughter came in alone to discuss her mother’s care with the physician, and we’re not sure how to bill it because the G codes for Medicare don’t cover this. Any suggestions?

Question submitted by Tiffany, San Antonio Urgent Care
A.I don’t believe that there is any method (reimbursable by Medicare) to code for discussions with the family of a patient, when the patient is not physically present. Medicare recognizes time a physician spends counseling a family member and/or other care decision maker only if the patient is present. The physician cannot count any time for counseling when the patient is not physically present in the room.

Medicare makes only one exception to this requirement, and this exception is rarely applicable to the urgent care situation. When, and only when, a physician is providing critical care to a patient, the physician time involved in obtaining a history or discussing treatment options with family members or other surrogate decision-makers may be counted to- ward critical care time, and only when the chart documents all of the following:

  1. that the patient is unable or incompetent to participate in giving a history and/or making treatment decisions;
  2. that the discussion is absolutely necessary for treatment decisions under consideration that day; and
  3. the treatment decisions for which the discussion was needed; and
  4. the substance of the discussion as related to the treatment

Sorry that I don’t have a better answer on this one, but we continue to wish you great success in your clinic.
Note: CPT codes, descriptions, and other data only are copy- right 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate le- gal advice.

Coding Symptoms of Infections, Modifiers for X-rays, and Counseling Family Members

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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