In order to facilitate appropriate and timely reimbursement for the services you provide to patients, it is important to have a good handle on the documentation that is needed for coding and billing purposes. Accordingly, this author shares key insights and advice in this arena.

Does your office’s billing staff have all the information they need to process a given claim? When can you bill for a consultation? What are the particularly important evaluation and management (E/M) codes that are relevant to what you do in daily practice? For the answers to these questions and more, let us consider some key coding and billing reminders.

Thorough documentation is critical for timely and appropriate reimbursement. One of the most important things is documenting all the services provided and linking them to the appropriate diagnosis code. Keep in mind that office staff doing data entry may not clearly understand the rationale behind the tests being ordered or services rendered when they are faced with the task of deciding which diagnosis code matches with a given service.

Indeed, clinicians must clearly document medical necessity in the medical record. In regard to the services one reports on the claim form with CPT and ICD-9-CM codes, clinicians must provide supporting narrative in the medical record.

Emphasizing Appropriate Evaluation And Management (E/M) Coding
The three key components for determining the level of E/M service are history, examination and medical decision-making. Every E/M code has requirements for the level of these three criteria. The selection should be consistent among all patients. Document your E/M services using the 1995 or 1997 HCFA/AMA documentation guidelines. (See “Pertinent Pointers On E/M Documentation”.)

Pertinent Pointers On E/M Documentation

- • E/M coding for new patient office visits, consultations, hospital admissions, emergency department visits and nursing home assessments require three out of three key components: history, examination and medical decision making. On the other hand, established patient office visits and subsequent hospital visits require only two of the three key components. • History is based on (a) the history of present illness (HPI); (b) the review of systems (ROS); and (c) the past history (including the patient’s medical, surgical, allergy history), family and social history (PFSH). The “weakest link” of these three determines the history level. • One can provide the history of present illness by giving the status of chronic or inactive medical problems. The status of three such conditions is the equivalent of four HPI elements. However, since this was a revision found in the 1997 Documentation Guidelines, you must also use the more specific 1997 exam guidelines. • One can incorporate the ROS (review of systems) and/or PFSH (past, family, social history) by reference from elsewhere in the record or from information recorded by ancillary staff or the patient. The provider must review the information and make comments as appropriate, including the date and location of the referenced information. • The review of systems (ROS) is often the weakest part of the history. I would suggest incorporating the ROS by reference, comment on the positives and pertinent negatives, and then state “all others negative” if you have indeed reviewed ten systems for current signs and symptoms. If the history is unobtainable, state why it is unobtainable. Keep in mind that some Medicare carriers and other payers are not being very generous with the phrase “all others negative” and some do not accept the term “noncontributory.” • Past history, family history and social history areas require documentation of only one item per category in order to get credit. • The 1995 exam criteria are more generic and require documentation about body systems or areas. The 1997 exam criteria are more specific. There are specialty specific criteria for many specialties. Be sure to review the musculoskeletal system specific exam criteria. You may use either the 1995 or 1997 exam guidelines. • Medical decision-making is based on the average: - number of diagnosis(es) or management options; - data to be reviewed; - risk (nature of presenting problem, diagnostic tests ordered, management options).

Many practices utilize audit tools and perform internal audits or ask for outside assistance to have an external audit conducted. If you have access to this service, it will be a great educational tool for you in monitoring your documentation and coding efforts.

When Should You Code By Time?
It is very beneficial to code by time when appropriate. If greater than 50 percent of the face-to-face encounter is spent counseling the patient or coordinating care, time becomes the controlling factor as opposed to the aforementioned criteria of history, examination and medical decision-making. Most of the E/M codes have a time associated with them as per the CPT book.

Be sure to document the total length of the encounter, the fact that greater than 50 percent of the visit was spent counseling or coordinating care, and provide a brief description of what was discussed.

Billing Consultations:
What You Should Know
When it comes to using consultation codes, one needs to ensure documentation of the three R’s: Request, Render an opinion, and send a Report. Keep in mind that consultations cannot be shared between a physician and a non-physician practitioner.

The three-year rule (for new versus established patients) does not apply to office consultations. In other words, a patient visit can be a consultation as many times as the criteria are met. For hospital consultations, only one consultation is allowed per hospital stay. The Centers For Medicare and Medicaid (CMS) as well as other payors are paying a lot of attention to the use and documentation of consultation coding so make sure you have a good understanding of the guidelines.

A Guide To Commonly
Utilized Modifiers

It is important to use modifiers appropriately. Here are some examples of frequently used modifiers.

• Modifier -25. This indicates a significant, separately identifiable E/M service given by the same provider on the same day as another procedure or service. Use it on the E/M code. When providing a procedure, you do not automatically get an additional E/M code. There needs to be a medically necessary and separately identifiable E/M service in order to bill for both a procedure and an E/M service.

• Modifier -24. One would use this when the same provider provides an E/M service during a post-op period. The visit must be totally unrelated. Your staff should use this modifier on the E/M code. In order to stay on top of your post-op global periods, regularly review the Medicare Fee Schedule as it is an excellent resource.

• Modifier -79. This modifier indicates an unrelated procedure by the same provider during a post-op period. One should use this modifier on the CPT code of the new procedure. A different (and unrelated) diagnosis would also be needed.

• Modifier -57. This modifier is used in regard to a decision for surgery with supporting documentation. Use this on the E/M code in order to keep this service out of the global package. One should only use this modifier on surgeries with a greater than 10-day global period.

• Modifier -59. This is the modifier of the last resort and will bypass CCI (Correct Coding Initiative) edits. Your staff may use this to identify procedures or services that are normally reported together when you need to indicate a particular circumstance such as a different encounter, a different procedure or a different site. However, be careful when utilizing this modifier because it might get you paid for something you should not have been paid for in the first place.

• Modifier -50. This is used to indicate a bilateral procedure during a single operative session. Medicare reimburses 150 percent and wants this listed as a one line item. The Medicare Fee Schedule identifies which surgeries allow this modifier.

• Modifier -51. Add this modifier when the clinician performs multiple procedures during the same operative session. Medicare pays 100 percent for the first procedure and 50 percent for each additional procedure. Again, be sure to consult your Medicare Fee Schedule.

By no means is this an all inclusive list of modifiers. Please see your CPT book for the complete list.

Top Tips For Coding
Minor Procedures
When it comes to coding and billing for common minor procedures, here are some key tips to keep in mind.
For example, fracture care codes include the application of the first cast but one may charge additionally for casting materials. Recasting is charged as a cast application plus materials. Instead, one may bill for stabilization and cast application if appropriate. There is often confusion about appropriate billing for fractures. Be sure to consult the CPT book as well as other coding guidance in this area.

Another important thing to remember is that joint aspirations/injections are coded based on the joint size. One should bill the medication additionally using the proper J codes from the HCPCS set of codes. There will be changes in the 2007 HCPCS codes for common injectables but they were not available when this issue went to press.

When coding for the care of lacerations, you need the size, location and type of repair (i.e. simple versus intermediate (layered) versus complex). If one codes multiple laceration repairs to the same anatomical site by the CPT code, you would add the lengths of the lacerations and code the total size as one CPT code.
Code a visit with an additional -25 modifier only if you have obtained a significant, separately identifiable history, performed an exam, and provided medical decision making over and above the procedure itself.
Suture removal is included at no charge. The only time one can bill for suture removal is when another physician (different group) placed the sutures. In this case, you would choose an appropriate E/M code.

When dealing with lesions, skin tags, etc., the size, location and method of removal or destruction must be specific. There are numerous codes to identify these services. For example, excision of benign and excision of malignant lesions have different series of codes based on location and size. The “excised diameter” refers to the diameter of the lesion plus the narrowest margins. There are examples pictured in the CPT book.
One may destroy lesions by a variety of methods. Be sure to indicate the number of lesions that were destroyed. There are also codes for paring, cutting, removal of skin tags, etc. For 2007, the codes for the destruction of benign lesions has been separated from the destruction of pre-malignant lesion codes.

There are codes for subcutaneous foreign body removal as well as codes for foreign body removal from the eye or other body part (ear, nose, etc.). There are also codes for nail debridement, avulsion, evacuation of subungual hematoma, etc.

Whenever you provide a service that seems to require more than the work of the “usual” office visit, ask yourself (or your staff) if there is a way to bill additionally for these services.

Why It Pays To Be Specific
With Your Diagnosis
If you write “extremity pain” on the charge ticket (aka superbill, encounter form), this is not specific enough. To find the specificity needed to accurately choose the ICD-9-CM code, your billing staff may be in a situation in which they have to review the chart and hope to find the exact location of the extremity pain. One can avoid these situations by ensuring specific diagnoses. In reality, coders often do not have the time to research for the more accurate information and ICD-9-CM codes are often “dumped” by the office billing staff to an unspecified code. As we prepare for ICD-10, specificity will become even more important.

There are no ICD-9-CM codes for “ruling out” or arriving at a “possible” diagnosis. For example, “ruling out a fracture” is not a diagnosis. In those instances, we can only code the signs and symptoms. If those signs/symptoms are listed on the charge ticket, the job of assigning ICD-9-CM codes becomes much easier.

Emphasizing The Importance
Of Linking The Diagnoses
And Procedures
List only the diagnoses addressed at the visit and link to the appropriate CPT code. Follow the reason for the encounter by noting chronic diseases that are being treated on an ongoing basis. One should list coexisting conditions if they affect that day’s visit. Proper ICD-9-CM coding can help substantiate the CPT coding and prove medical necessity. Linking each CPT code to a diagnosis code will facilitate accurate charge entry and less work on the back end to fix denied claims.

Stay On Top
Of New Coding Changes
And Special Billing Rules
Be aware of what is new for this year and incorporate those changes into your billing system, charge tickets and any “help sheets” your office’s billing staff may be using. Watch for information from your specialty society on coding changes that may affect your practice. Your Medicare carrier will also be providing information on its coding and payment policy changes for the new year.

Make sure your staff is billing appropriately for your services. Some insurance companies will want you to be credentialed and have your own provider number. Your scope of practice and state rules will come into play. Medicare has very specific language on how your services are to be billed. While billing “incident to” a physician will provide higher reimbursement, it limits the services you can provide. Also bear in mind that one can only provide “incident to” services in the office setting.

One must also ensure that all “incident to” criteria are met. For example, if you are billing “incident to” a provider, then that provider must have already established a care plan for that patient and his or her condition. Another “incident to” rule is that the physician must be on the premises while you are providing these services.

Bear in mind though that the insurance companies you deal with may or may not follow all the “incident to” rules.

Final Notes
While this article is not an all-inclusive list of helpful hints, this may be a start. Education and communication are fundamental to the entire coding and billing process, and facilitating proper reimbursement for services rendered.