When is a patient considered new? If you've never seen the patient either in your office or in the hospital or if the patient hasn’t been seen by anybody within your group, within your specialty in the last three years. Learn more with this evaluation and management coding training article.
So in the note, it said, “As you know, she's a 60-year old woman who I have seen in the past for a rash.” Well, we don’t know what past means. Does that mean 7 years ago, 20 years ago? Or does that mean 6 months ago?
So in this instance, the physician wasn’t very clear as to whether or not the patient would be considered new or established. We may have to go with the code choice that he gave. Or we'd have to look into the medical record a little bit further. But this note doesn’t clearly tell us if the patient was new or if the patient was established.
So what about a consultation? When is the visit of consultation? It's when another physician asks us for an opinion. We offer that opinion. We may actually take care of the patient for that condition. But we're offering the opinion and then we're giving the patient the opportunity to decide what he or she would like to do with that information.
So the physician sends the patient to us. There's a documented reason in the chart. The service is rendered. And we send a letter back to that requesting physician with our recommendations in regard to the patient’s treatment. And if we do decide to initiate care, we also indicate that and that we would keep the physician in the loop in that regard.
Our expert points out in a medical coding basic training event that there are two types of consult at this point. There's your office or other outpatient consults. This would be in your office if you're consulting an ED. You'd also have in-house consults. Those are one you're seeing patients on the floor at the request of another physician.
Keep in mind that Medicare no longer recognizes these codes sets. Not that they don’t pay for consultations, they just don’t pay for the codes described as consultation. You can see a Medicare patient in consultation. You would be using the appropriate new patient code or established patient codes in the office setting or initial and subsequent service codes in the in-house environment.
For instance, a physician’s note says, ‘I saw Sarah today with extreme tenderness over her left thumb with the history of broken glass and she was seen in the past for rash’. Does this verbiage satisfy the consultation criteria?
And usually, you would want to see something that would say, “Dear Dr. (Man), thank you for sending Sarah today to me in consultation.” The physician did write at the end, “Thank you for getting her back to see me. I will certainly let you know how things go.”
So was the original physician, Dr. (Man), was he sending (Sarah) to this physician to handle this issue or was this a consultation to get an opinion? And that's not really clear in this verbiage. Again, being very clear and to the point is probably the better way to go.
“I saw Sarah in consultation today for her extreme tenderness over her left thumb.” That would have clearly illustrated that the physician, the consulting physician did believe that this was a consultation.
The E/M service, the procedure and the x-ray that was done can all be billed for this service rendered during this visit. The diagnosis code would still be the same. The E/M service diagnosis code would be the same as the procedure diagnosis code which would also be the same as the x-ray but that doesn’t mean that the services aren't billable.
So you want to check with your payers. But most of the time, these are situations where this is an appropriate time to bill both the E/M service and the procedure.
Modifiers Training Tip: The 25 modifier is recommended. A consultation in the ED with a simple incision and drainage to follow-up floor consultation, procedures done in the office, both separately identifiable services. You can bill them if you have your E/M service documented appropriately and then the procedure documented appropriately.
The -57 modifier is used when you do a consultation let's say in the ED and the patient has an appendicitis as per modifiers coding guidelines. If you're able to do a full visit with the patient to determine what their issue is, and then take them to surgery, the -57 modifier is appropriate.
If however, you had to take the patient emergently to the OR, then you wouldn't have your E/M service and you thus wouldn't use your -57 modifier as per modifiers coding guidelines.
Your office visit with immediate admission to the hospital for surgery the next morning, you would put your -57 modifier on your visit in the office to the surgery the next day. In some instances again, you want to check with your payers. Some of them won't allow that visit to be billed even with the -57. Most will. You’ll just want to make certain that you're checking.
Our expert mentioned in a medical coding basic training event that major procedures done on the same day or the next calendar day are when you use the -57. And how you remember that is the -25 is a small number. Minor procedures, the -57 is a larger number. That would be your major procedures.
For your new patients in consults, you want to have three out of the three components we talked about history, exam and decision making. If you don’t get that full robust history, let's say you just get an expanded history but you do a comprehensive exam and you have moderate decision making. The highest level of service you'd be able to bill would be your level two service, a 99202 and 99242 simply because you didn’t ascertain all of the history components needed for that level four service, according to the E&M code guidelines.
Conversely, with your established patients or your subsequent daily patient visits, that history of expanded problem focused with a comprehensive exam and higher decision making would get you to a level five established patient simply because you only need to have two of the three major components.
So let's go back to this note and let's determine exactly what code level we're able to select as per evaluation and management coding guidelines. We have an extended history of present illness. We don’t have any review of systems. We do have a past under past family and social histories.
Under the exam, we have expanded problem focused for the ‘95 guidelines or just problem focused for the ,97s. The decision making is that we had a new problem. We didn’t have data because we billed for the x-ray. And then for the risk, the minor procedure, no risk there it was low.
So using the 1995 guidelines, if we presume that this patient was established because he had mentioned that he saw her in the past for the rash, then the 99213 with the -25 modifier would be appropriate otherwise, 99201 or the 99241 if it was billed as a consultation and documented appropriately. Conversely with the 1997 guidelines, you'll see that the code level is one level down 99212 with the -25 modifier and that's because of the way we have the score out the exam.
Get hospital Medicare billing training online with healthcare audio conferences available at AudioEducator