Coding and Billing
This coding expert answers
common coding questions to help you run a more efficient practice
September 2003
Although most physicians and staff are very comfortable with respect to billing the various types of Evaluation and Management (E/M) services, frequent questions come up for less common or unique situations. In this article, I’ll address a few scenarios that may provide some insight and guidelines when these situations arise.
Q: Can you please tell me how to bill for seeing a patient in his/her private residence. Believe it or not, I still make “house calls” for some of my more challenging, home-bound patients. What I need to know is:
1. Which codes should I use?
2. What is the two-digit place of service designation?
3. Can I bill a new patient visit, even if I’ve seen the patient before in the office?
4. Can I bill a consultation if the family requests that I make the house call?
A: The CPT codes for home services are divided between "new patient visits" (99341 - 99345) and "established patient visits" (99347 - 99350). These codes are subject to the
3-year new patient rule. Specifically, the rule states,
“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years.”
So if you (or another member of your dermatology group) have seen the patient face-to-face in your practice within the past 3 years, you can’t bill a new patient home visit. You will have to use the established home visit codes (99347 - 99350).
The outpatient consultation codes (CPT codes 99241 - 99245) are not appropriate for use in the patient home setting — regardless of who requested you to make the house call. The outpatient consultation codes are only applicable for use in the office setting, the emergency room, and the hospital observation unit.
The two-digit place of service designation for patient home is 12.
I hope these answers clarify some of these issues for you.
Q: Are there any consultation codes that one can use that don’t require a letter to the consult-seeking physician after the patient has been seen?
A: First, let’s review what the criteria are for justifying the billing of a consultation:
1. Your chart note must indicate that you received a request from an appropriate source and that the source requested your advice and opinion regarding a specific dermatologic condition.
2. You may initiate care, write prescriptions, do surgery, etc., and still bill the E/M service as a consultation.
3. You may continue to see the patient and care for the problems after the initial consultation and still bill the initial visit as a consultation, unless, prior to you seeing the patient a complete transfer of care was agreed upon between you and the consult-seeking provider. (Note: This complete transfer of care occurs very infrequently in the specialty of dermatology.)
4. You must be able to demonstrate that you provided a written report to the consult-seeking provider regarding your findings. A copy of the progress and/or operative note is an acceptable alternative to the formal consultation letter as long as the chart note indicates that a copy was made and forwarded to the consult-seeking physician.
The above four criteria are required in order to bill the outpatient consultation codes (e.g., 99241 - 99245). In the inpatient setting, such as hospitals and skilled nursing facilities, the report of findings, (e.g., the consultation letter) may consist of an appropriate entry in the common medical record of that facility. Most inpatient facilities have special consultation forms that the consulting physician completes after the consultation has been completed.
So the answer to your questions is that in the inpatient setting, no actual letters are required.
Q: Are we allowed to charge for “no-shows” when patients don’t keep their appointments? Are we allowed to have no-shows prepay to assure that they show up? Is there any code we can use to bill insurance companies for these missed appointments?
A: My first piece of advice is to always check with your local healthcare attorney to assure that you’re aware of any state statutes that may exist. In the absence of such limiting law, it’s my understanding that you can charge patients for missed appointments. However, there must be a written policy that outlines this policy for your patients.
The policy must be distributed to all of your patients in advance, so they know and understand that you charge for missed appointments. The policy can’t be discriminatory. This means that you must bill all patients for no-show appointment no matter the type of insurance they have, no matter their age, or financial class.
About your question regarding prepayment of visits, I personally think it’s a very bad idea. It doesn’t say much about the goodwill of your practice and makes your practice look like its main goal is money, money, money. Additionally, I don’t think you’ll get patients to agree to this. Would you, if you were the patient? Think about it. What if you became ill, had an emergency or death in the family, or simply wrote down the wrong appointment date, would you want to be penalized for these situations?
This type of policy is very anti-patient. After all, you’re supposed to be in the patient care business. What type of exceptions would you make? It really needs to be a well-thought-out policy.
You can’t bill any insurance company for no-show appointments. You can only bill patients. There are no CPT or HCPCS codes for missed visits because these aren’t billable, covered services by any carrier — nor is billing for these services to carriers allowed.
My personal suggestion here is to develop a better policy on appointment verification, develop a better method of scheduling, and establish better lines of communication between you and your patients. The results are far more rewarding that billing patients for missed appointments.
Although most physicians and staff are very comfortable with respect to billing the various types of Evaluation and Management (E/M) services, frequent questions come up for less common or unique situations. In this article, I’ll address a few scenarios that may provide some insight and guidelines when these situations arise.
Q: Can you please tell me how to bill for seeing a patient in his/her private residence. Believe it or not, I still make “house calls” for some of my more challenging, home-bound patients. What I need to know is:
1. Which codes should I use?
2. What is the two-digit place of service designation?
3. Can I bill a new patient visit, even if I’ve seen the patient before in the office?
4. Can I bill a consultation if the family requests that I make the house call?
A: The CPT codes for home services are divided between "new patient visits" (99341 - 99345) and "established patient visits" (99347 - 99350). These codes are subject to the
3-year new patient rule. Specifically, the rule states,
“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years.”
So if you (or another member of your dermatology group) have seen the patient face-to-face in your practice within the past 3 years, you can’t bill a new patient home visit. You will have to use the established home visit codes (99347 - 99350).
The outpatient consultation codes (CPT codes 99241 - 99245) are not appropriate for use in the patient home setting — regardless of who requested you to make the house call. The outpatient consultation codes are only applicable for use in the office setting, the emergency room, and the hospital observation unit.
The two-digit place of service designation for patient home is 12.
I hope these answers clarify some of these issues for you.
Q: Are there any consultation codes that one can use that don’t require a letter to the consult-seeking physician after the patient has been seen?
A: First, let’s review what the criteria are for justifying the billing of a consultation:
1. Your chart note must indicate that you received a request from an appropriate source and that the source requested your advice and opinion regarding a specific dermatologic condition.
2. You may initiate care, write prescriptions, do surgery, etc., and still bill the E/M service as a consultation.
3. You may continue to see the patient and care for the problems after the initial consultation and still bill the initial visit as a consultation, unless, prior to you seeing the patient a complete transfer of care was agreed upon between you and the consult-seeking provider. (Note: This complete transfer of care occurs very infrequently in the specialty of dermatology.)
4. You must be able to demonstrate that you provided a written report to the consult-seeking provider regarding your findings. A copy of the progress and/or operative note is an acceptable alternative to the formal consultation letter as long as the chart note indicates that a copy was made and forwarded to the consult-seeking physician.
The above four criteria are required in order to bill the outpatient consultation codes (e.g., 99241 - 99245). In the inpatient setting, such as hospitals and skilled nursing facilities, the report of findings, (e.g., the consultation letter) may consist of an appropriate entry in the common medical record of that facility. Most inpatient facilities have special consultation forms that the consulting physician completes after the consultation has been completed.
So the answer to your questions is that in the inpatient setting, no actual letters are required.
Q: Are we allowed to charge for “no-shows” when patients don’t keep their appointments? Are we allowed to have no-shows prepay to assure that they show up? Is there any code we can use to bill insurance companies for these missed appointments?
A: My first piece of advice is to always check with your local healthcare attorney to assure that you’re aware of any state statutes that may exist. In the absence of such limiting law, it’s my understanding that you can charge patients for missed appointments. However, there must be a written policy that outlines this policy for your patients.
The policy must be distributed to all of your patients in advance, so they know and understand that you charge for missed appointments. The policy can’t be discriminatory. This means that you must bill all patients for no-show appointment no matter the type of insurance they have, no matter their age, or financial class.
About your question regarding prepayment of visits, I personally think it’s a very bad idea. It doesn’t say much about the goodwill of your practice and makes your practice look like its main goal is money, money, money. Additionally, I don’t think you’ll get patients to agree to this. Would you, if you were the patient? Think about it. What if you became ill, had an emergency or death in the family, or simply wrote down the wrong appointment date, would you want to be penalized for these situations?
This type of policy is very anti-patient. After all, you’re supposed to be in the patient care business. What type of exceptions would you make? It really needs to be a well-thought-out policy.
You can’t bill any insurance company for no-show appointments. You can only bill patients. There are no CPT or HCPCS codes for missed visits because these aren’t billable, covered services by any carrier — nor is billing for these services to carriers allowed.
My personal suggestion here is to develop a better policy on appointment verification, develop a better method of scheduling, and establish better lines of communication between you and your patients. The results are far more rewarding that billing patients for missed appointments.
Although most physicians and staff are very comfortable with respect to billing the various types of Evaluation and Management (E/M) services, frequent questions come up for less common or unique situations. In this article, I’ll address a few scenarios that may provide some insight and guidelines when these situations arise.
Q: Can you please tell me how to bill for seeing a patient in his/her private residence. Believe it or not, I still make “house calls” for some of my more challenging, home-bound patients. What I need to know is:
1. Which codes should I use?
2. What is the two-digit place of service designation?
3. Can I bill a new patient visit, even if I’ve seen the patient before in the office?
4. Can I bill a consultation if the family requests that I make the house call?
A: The CPT codes for home services are divided between "new patient visits" (99341 - 99345) and "established patient visits" (99347 - 99350). These codes are subject to the
3-year new patient rule. Specifically, the rule states,
“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years.”
So if you (or another member of your dermatology group) have seen the patient face-to-face in your practice within the past 3 years, you can’t bill a new patient home visit. You will have to use the established home visit codes (99347 - 99350).
The outpatient consultation codes (CPT codes 99241 - 99245) are not appropriate for use in the patient home setting — regardless of who requested you to make the house call. The outpatient consultation codes are only applicable for use in the office setting, the emergency room, and the hospital observation unit.
The two-digit place of service designation for patient home is 12.
I hope these answers clarify some of these issues for you.
Q: Are there any consultation codes that one can use that don’t require a letter to the consult-seeking physician after the patient has been seen?
A: First, let’s review what the criteria are for justifying the billing of a consultation:
1. Your chart note must indicate that you received a request from an appropriate source and that the source requested your advice and opinion regarding a specific dermatologic condition.
2. You may initiate care, write prescriptions, do surgery, etc., and still bill the E/M service as a consultation.
3. You may continue to see the patient and care for the problems after the initial consultation and still bill the initial visit as a consultation, unless, prior to you seeing the patient a complete transfer of care was agreed upon between you and the consult-seeking provider. (Note: This complete transfer of care occurs very infrequently in the specialty of dermatology.)
4. You must be able to demonstrate that you provided a written report to the consult-seeking provider regarding your findings. A copy of the progress and/or operative note is an acceptable alternative to the formal consultation letter as long as the chart note indicates that a copy was made and forwarded to the consult-seeking physician.
The above four criteria are required in order to bill the outpatient consultation codes (e.g., 99241 - 99245). In the inpatient setting, such as hospitals and skilled nursing facilities, the report of findings, (e.g., the consultation letter) may consist of an appropriate entry in the common medical record of that facility. Most inpatient facilities have special consultation forms that the consulting physician completes after the consultation has been completed.
So the answer to your questions is that in the inpatient setting, no actual letters are required.
Q: Are we allowed to charge for “no-shows” when patients don’t keep their appointments? Are we allowed to have no-shows prepay to assure that they show up? Is there any code we can use to bill insurance companies for these missed appointments?
A: My first piece of advice is to always check with your local healthcare attorney to assure that you’re aware of any state statutes that may exist. In the absence of such limiting law, it’s my understanding that you can charge patients for missed appointments. However, there must be a written policy that outlines this policy for your patients.
The policy must be distributed to all of your patients in advance, so they know and understand that you charge for missed appointments. The policy can’t be discriminatory. This means that you must bill all patients for no-show appointment no matter the type of insurance they have, no matter their age, or financial class.
About your question regarding prepayment of visits, I personally think it’s a very bad idea. It doesn’t say much about the goodwill of your practice and makes your practice look like its main goal is money, money, money. Additionally, I don’t think you’ll get patients to agree to this. Would you, if you were the patient? Think about it. What if you became ill, had an emergency or death in the family, or simply wrote down the wrong appointment date, would you want to be penalized for these situations?
This type of policy is very anti-patient. After all, you’re supposed to be in the patient care business. What type of exceptions would you make? It really needs to be a well-thought-out policy.
You can’t bill any insurance company for no-show appointments. You can only bill patients. There are no CPT or HCPCS codes for missed visits because these aren’t billable, covered services by any carrier — nor is billing for these services to carriers allowed.
My personal suggestion here is to develop a better policy on appointment verification, develop a better method of scheduling, and establish better lines of communication between you and your patients. The results are far more rewarding that billing patients for missed appointments.
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