This quiz has been designed to be general in nature, so it is a viable test for almost any sort of practice. The questions below are not specific to any specialty. They are designed to show a general understanding of the basics of procedural coding for medical services. We have avoided cases that would require a high level of understanding for any specific area of medicine. The test is meant to be open book and open computer. Should you need a quiz specific to your specialty, please contact us via the e-mail link on any page, and we'll be happy to customize one especially for you.
PLEASE NOTE: All questions should be answered using current Medicare guidelines and appropriate procedure codes.
An established patient visits office for routine follow-up ten days after Physician removed a 2cm benign lesion from her forearm. Physician examines the site and removes the stitches.
Patient asks Physician to check her cholesterol 'just to be sure it's ok'. Physician orders a cholesterol test. A specimen is obtained which will be tested by your in-house lab later in the day.
Patient also complains that she just cannot hear as well as she once could. Physician asks patient about her personal and family history concerning hearing loss. He also asks about other possible symptoms such sinus drainage, sore throat and dizziness. He examines her ears, listens to her chest and checks her eyes and throat. Both of her ears are blocked with impacted cerumen - which he removes using a cerumen spoon (as opposed to irrigation only.)
Test results reveal Jane Smith does have dangerously elevated cholesterol. Patient is called and a follow-up is scheduled.
What procedure codes may be billed for these services? Should anything else be done to get this claim paid?
- 99214-24 Presuming you have properly documented the history and examination
- 82485 (Check with your supplier to verify cholesterol test code)
According to CPT, to bill 99214, two of the three components must be performed and documented:
- Detailed history: Chief complaint, extended history of present illness, problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient's problems.
- Detailed exam: An extended examination of the affected body area(s) and other symptomatic or related organ system(s)
- Medical decision making of moderate complexity: A multiple number of diagnoses or management options, a moderate amount of data to be reviewed and a moderate risk of complications, morbidity or mortality.
Although not technically required, it can be argued that medical decision making should always be included as one of the two required components. Medical decision making is directly linked to medical necessity. Although in this case, the loss of hearing appeared to be associated with impacted cerumen, the physician assessed other possible causes including respiratory and neurological.
A -25 modifier should be added to the evaluation and management code to show this is an unrelated evaluation and management service during a global period.
Removal of impacted Cerumen-59
-59 indicates that this is a separate procedure from the benign lesion removal. The procedure will be denied without the modifier. You may only bill 1 code for the removal of impacted cerumen. By definition, the removal of impacted cerumen is for one or both ears.
The cholesterol test is a screening exam. Even though the screening test later revealed that the patient did have a cholesterol problem, such was not known at the time of the screening. Thus, an ABN for laboratory services is required.
In addition modifier GA should be added to the test to show an ABN has been signed. Without the GA modifier, the patient's EOMB from Medicare will show that he has no liability for the charge. By adding the GA modifier, you may bill the patient directly for the laboratory services.
The services rendered to examine and remove the stitches from the surgical site are not billable. They are part of the global surgery package.
Patient suffers from multiple medical problems. Among the problems is widespread arthritis. Physician performs a thorough evaluation and management service. Because of a confirmed bacterial infection, you give the patient a 250mg injection of Rocephin. In addition, Physician injects each of patient's painful knees with 40mg of Depomedrol per knee. What, if any, procedure codes should be used for the injections? Assume that the evaluation and management code is 99213.
- 20610-50 (Some carriers prefer 20610-RT and 20610-LT)
90782 would not be charged. It is considered a component of 99213. Nor would Xylocaine be billed. A surgical kit and local anesthetic are included in the base charge for 20610.
Modifier 25 is needed on 99213 because a significantly separate evaluation and management procedure was performed in addition to evaluating the knees.
Modifier 50 indicates that the joint injection was bilateral. Be sure to double the charge.
A long term patient is no longer able to care for his medical needs without assistance. Physician orders home health services and reviews and signs the certification form for home health care. During the second month of home health care, the home health nurse calls the Physician three times about abnormal labs and adjustments to medications. Physician spends and appropriately documents thirty minutes of time in reviewing the patient's medical data and modifying orders. What, if anything, may be billed for these services?
- G0180 - For the initial certification
- G0181 - For the 30 minutes in care plan oversight during a calendar month
Medicare does pay a physician for assisting with home health care services. However, since its definition of home health care differs from the CPT definition, the above codes must be used instead.
Patient presents at office with severe shortness of breath and nausea. Patient complains of pressure in his chest radiating into his shoulders and arms. Physician does a brief assessment in the office and immediately calls for a wheelchair to take the patient to the emergency room at the adjoining hospital. With the assistance of the emergency room physician, patient is stabilized. Physician does a comprehensive history and physical and admits the patient to the hospital. Physician documents in his notes that actual times in stabilizing and treating the patient which amount to two hours. What should be billed?
In most cases, only one evaluation and management code can be billed per day. The hospital admission is the highest level of service and should thus be billed. Prolonged attendance may also be billed for one hour since the typical time of 99223 is 70 minutes. The remaining 50 minutes is in excess of the 30 minutes required to bill 99356.
Based on the information in this example, critical care would not be an appropriate code. Although an MI is inferred from the example, there is no documentation to support the fact that it actually occurred.
Patient was terminal. Nothing more could be reasonably done except make the patient comfortable. After discussing his condition with patient and family, patient requested to go home. Physician prepared all discharge papers and made the original contact with a hospice agency to arrange for in home care. Sadly, patient quietly dies in his hospital bed prior to leaving for home. Physician then pronounces the patient. Physician is excellent with documentation. All notes and orders are appropriately headed with date and time. Can anything be billed?
- 99238 or 99239 (depending on whether 30 minutes or more of time was involved)
Medicare allows reimbursement for the services associated with the pronouncement of death. More and more carriers are now allowing for discharge services to be paid on the date of death provided all components of the discharge summary are properly completed. If the requirements of a hospital discharge are not completed, the service must be billed using the CPT code that most accurately describes the work performed. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.
There is no specific code for the pronouncement of death.
Expect a denial on this claim. However, with the physician's dated and timed documentation, an appeal should result in a reversal.
Patient is in a Nursing Facility. Nurse calls Physician and says Patient is extremely agitated and that the PEG tube continually comes out. Physician visits the patient and replaces the PEG tube. He also reviews the medical records and does a history and physical that qualify as expanded problem focused. He changes the orders to different medications and includes an order to keep him informed as to any changes in patient's behavior with the new medications. How would these services be coded?
Modifier 25 is necessary on the evaluation and management code to indicate that a significant, separately identifiable evaluation and management code was provided.
Patient has a long history of hypertension and cholesterolemia. Her cholesterolemia has been managed successfully for several years with Lipitor. Patient has read recent articles in the press concerning an elevated risk of kidney failure associated with Lipitor, and seen late night commercials from lawyers urging Lipitor patients to call them if they have certain side effects. Even though her visit was meant to be a brief, routine visit to ensure the treatment plan was still having its desired effect, Physician spends thirty-five minutes talking to the patient. During most of the visit they discussed the serious side effects of elevated cholesterol vs. the slight possibility of life-threatening complications. Physician discusses alternate drugs that are available and counsels her on things she can do to decrease her statin dosage including taking her medication with Maalox TC. He explains to her that since the body makes its own cholesterol, diet alone may not be enough to control her cholesterol. He suggests she supplement daily with CoQ10 since Lipitor is known to reduce the levels of this naturally occurring coenzyme. After the discussion, patient decides to remain on her current regimen. You briefly summarize the discussion and the amount of time you spent explaining to the patient in patient's medical records. What level evaluation and management service was performed?
For office patients, there are two separate ways to code a visit. The most common way is based on the key component of history, exam and decision making. An alternate way which is frequently overlooked is by the amount of time spent, when counseling and coordination dominates the encounter.
According to the Evaluation and Management Service Guidelines in the American Medical Association's CPT:
When counseling and/or coordination of care dominates (more than 50% of the entire visit) the physician/patient and/or family encounter (face-to-face time in the office, outpatient setting or floor/unit time in the hospital/nursing facility), the time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.
Time should only be used as criteria to select a level of office service when counseling and coordination of care dominate the encounter.
Critical care codes and add-on prolonged services codes also consider time.
Forty-two year old new patient presents asking for a complete physical. Physician performs a comprehensive history and physical and runs appropriate diagnostic and laboratory tests. The tests show that the patient's blood sugar and cholesterol levels are both at the high end of normal. Patient is also thirty pounds overweight. Physician spends twenty minutes discussing the results of the tests, educating the patient and recommending a nutritionist and several good books to help. How would you bill for the evaluation and management components of this visit only?
Preventive services are not covered by Medicare. However, since they are never covered by Medicare, an ABN is not required. Best practices, however, would give the patient a Notice of Exclusion from Medicare Benefits.
The preventive medicine individual counseling codes, 99401 through 99404 cannot be charged at the same time as the well patient exam since counseling is an aspect of the code.
Unless the screening tests are among Medicare's few allowed screening tests, an ABN needs to be obtained for any x-rays, laboratories, etc.
Unlike Medicare, many private insurance plans DO provide coverage for an annual physical. When originally verifying a patient's coverage, a question should always be included as to what preventive services are covered under the patient's policy. Private insurance conventions vary widely here. It's important to become familiar with the variances in billing for well patient services in your area. Some plans will bundle a series of tests and an exam under a single code. If you unbundle and charge for each component separately, only the single code will be paid - at a rate less than the insurance company would have allowed if you had followed their coding rules.
Patient had visited the office three days earlier complaining of a 5cm 'knot' on his leg. After an appropriate assessment, physician determined that the knot was a fibrous lesion inflamed by a localized infection, prescribed antibiotics and scheduled a return visit for removing lesion. Prior to the procedure, physician did a cursory exam of the site. Physician removed lesion including margins, did extensive cleaning of the site which included both foreign matter and devitalized tissue and closed the site. The excised diameter was 6cm. How would you code the visit during which the lesion was removed?
It would be inappropriate to code an evaluation and management code because the decision for surgery was actually made on the prior visit. Although billing an evaluation and management code and adding modifier -57 to indicate decision for surgery would result in payment, such would be a false claim as the service was not rendered on the day of the procedure.
-22 indicates the excision was unusual. If additional documentation is submitted to Medicare with the claim showing why the procedure was unusual (presence of infection and size of excision) and indicating the approximate additional work involved in the procedure, ie: 'This procedure involved 25% more work than a typical removal because Medicare may pay more on the procedure.
Although simple repairs are included with the excision charge, intermediate repairs are not. According to the CPT definition of intermediate repair, 'Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair'.
Two patients received colo-rectal screening tests. Both patients are in their 60s. Patient One had been previously tested, ten months earlier, using the immunoassay test. Physician elects to test with the fecal occult blood method this time. Patient Two, who had not been previously tested, was tested with the fecal occult blood method. In both cases, three simultaneous samples were tested. What needs to be done to ensure payment?
- Patient One - G0107-GA
- Patient Two - G0107
Patient One - Absent additional symptoms, Patient One's test would not be covered. A screening for colo-rectal cancer is only allowed once every twelve months. Thus, an ABN would need to be signed by patient. The ABN should include the reason that Medicare does not pay for colo-rectal screening exams more than once every twelve months. A -GA modifier would be added to the proper CPT test.
Patient Two - Patient Two will be covered because beginning in 2004, Medicare is covering immunoassay-based testing as well as occult blood testing.
82270 is not the correct code in this case. 82270 is for diagnostic use. G0107 is for screening tests.