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DAVID STERN, MD (Practice Velocity)

Q.How would you define the difference between an expanded problem-focused exam and the detailed exam in the 1995 evaluation and management coding guidelines?
– Question submitted by Eddie Stahl, Medical Staff Director, Tennessee Urgent Care Associates

A.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 encounters, so CMS has simply allowed providers to use whichever set of guidelines they feel most comfortable using.

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

A.To use 99211 properly, the chart will need to demonstrate clearly that the nurse did an evaluation and management of the patient’s condition. I have previously 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 “outpatient clinics.” We are confused on the place-of-service code because place-of-service 22 states the facility is part of the hospital, but the urgent care seems more appropriate. However, we were told it was not appropriate because 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.

A.No matter what your location (hospital, freestanding, 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 representative does not know the answer—or, even worse, gives us the wrong answer.

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

A.Physicians may use one of three coding methods in this situation. Your radiologists may have a strong preference for one or the other.

  1. Bill technical component only (modifier -TC); then the radiologist will bill the professional component (mo ifier -26).
  2. Bill global code. The radiologist would be an employee of your clinic who would sign an independent contractor agreement and work under the guidelines provided by the IRS for independent
  3. Bill global If the radiologist does an over-read only when you are asking a radiologist a specific question, then you may want to bill the global for the x-ray and then the radiologist will bill a second read with modifier -77 -26 (repeat procedure by another physician).

Although this is a legitimate coding method that has been specifically authorized by several Medicare carriers, the radiologists may not want to use this coding method, as some plans may not pay for the second opinion reading of the x-ray.
Whatever method you choose, you may want to specifically get an opinion from a lawyer with expertise in this field and save the written opinion in your compliance files.

Q.In reviewing one payor’s EOBs, I noted that a patient was seen and had an influenza A/B screen. The payor only reimbursed $7.04 for the test, which does not even cover the purchase price of the test.

It seems crazy that we would not even get back 50% of our outlay. Could we code for two tests or units, as we are testing for both influenza A and influenza B?

All the flu tests that we do are for A and B. If we were able to charge for two tests, at least we would come close to covering our cost for the product, which is close to $16 per test kit.

– Question submitted by John Opyoke, Trinity Urgent Care, Trinity, FL

A.Great point! Coding influenza tests depends on the type of test being done. If the test gives a generic “positive flu” result, then use code 87804 only once. If the test gives one result for influenza A and a second result for influenza B (example: positive for flu A and negative for flu B), then use code 87804 twice.

You would want to append modifier -59 (repeat procedure, same physician) to the second code. As always, local payors may have specific policies regarding coding and reimbursement for influenza test, so it is a good idea to check with them before submitting billing for these tests.

Note: For Medicare, you will want to also add modifier –QW to this and all other CLIA-waved tests.

Readers’ Coding Inquiries

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