Lately, questions have been coming at me from left to right on a variety of topics. Although none of the questions in this month’s column have a single theme, hopefully, you will find information that will relate to your practice.
Q: I am working on my documentation for evaluation and management (E/M) visits. With respect to the History of Present Illness (HPI), I have this question: If a rash is described as “asymptomatic” in my chart note, does this fulfill the quality component of the history?
A: First of all, the quality factor of the HPI factors describes the character of the sign or the symptom. For example, if the rash was itchy, then the quality might be described as burning or stinging.
The most common HPI factors documented by dermatologists are usually, location, duration, signs and symptoms, and severity. Those four can meet the HPI factor requirement for any level of care; up to a level five.
So let’s assume that you are trying to determine if the patient’s rash or lesion is symptomatic (listed under signs and symptoms; not quality), it is not enough to simply state, “Asymptomatic.”
You need to document the questions you asked to which you got a negative response. For example, “Denies pain, itching, tenderness.” That would count for three HPI factors. Likewise, if the patient has a lesion, you might document, “Denies enlarging, getting darker, or bleeding.” Again, this would represent three HPI factors.
Q: I have a question about documenting the HPI factors for an E/M visit in the situation where I’m trying to determine the duration of a lesion, but the patient has stated that it is unknown (e.g., he or she can’t really remember how long the lesion has been present). In a case such as this, if I document “unknown duration”, does that count as an HPI factor under the duration part?
A: Yes it does, and that’s because you asked the question and documented the answer.
Q: When a patient comes to the office as the result of a consultation for a specific problem — let’s say a spot on the ear — can I only charge the consultation based on that one problem? Or, can I bill the level based on everything I found during the history and exam? I know that there are many new guidelines for consultations, and I certainly don’t want to overcode.
A: You meet the criteria for a consultation if first, you received a written request for it and noted the specific problem you were asked to provide advice and opinion on in your progress report. Also important is the fact that you send a letter of your findings.
The request for a consultation is not a request for the dermatologist to provide a certain level of care; it’s for advice or opinion on a specific problem. As the dermatologist, you also need to address any problems that the patient brings up during the visit and/or that you find during your examination. You then base the level of service on all that was done and documented; not just on the specific problem requested by the referring doctor.
Q: I am a dermatologic surgeon and hope that you can clarify an issue that seems to be the basis of dispute among myself and my partners, who are also all dermatologists. Here’s the specific scenario: A cancerous lesion is excised from the upper chest and I perform the repair. In order to accomplish that repair, I make cuts that go into the neck area. Can I select the repair code based on the neck (which pays more), or must I code based on the chest? This type of situation also frequently happens on the face, and the difference in payment can be quite significant.
A: That is a very good question.
You must code to the site of the skin cancer — not to where extensions are made in order to repair the site.
Q: I am a dermatopathologist and I read slides, not only for my specialty group of eight dermatologists, but also for other groups in the area. The group I’m with has never had a dermatopathologist before. Because I am very new to the group and new to billing (I am retired military), I just want to track my charges and make sure that my billing department is correctly coding and billing my services.
Here’s an example of the type of situation I come across: Yesterday, I received 14 bottles containing 14 lesions that were shave removed from a single patient. All of the lesions turned out to be benign intradermal nevi except for one lesion that was malignant. How should that claim be coded? (By the way we also make our own slides in-house.)
A: Since pathology services are not subject to the multiple surgery reduction rule, you should always bill these services in units on one line of the CMS 1500 form. Do this regardless of whether you bill globally (this means billing for both the technical and professional components), or just the professional component or only the technical component. In your case, you would bill 88305 on one line with 14 units indicated in block 24G of the old or new CMS-1500 claim form.
Your staff may make the argument that you can’t bill all of these components on the same line because one of the lesions has a different diagnosis. However, that doesn’t matter. As long as you have the correct diagnoses listed in the chart, or, in your case on the pathology reports, you just pick one of the covered diagnoses and link it to 24E of the claim form. You can list all the diagnoses in block 21, but only one diagnosis needs to be linked to a CPT code. If your staff would bill one of the 88305 on a separate line, it would be denied as a duplicate charge.
Q: How many years is it between using the consult codes (99241 to 99245) for an established patient? I thought it was 3 years, but I can’t seem to find the answer anywhere I’ve searched.
I belong to an office managers group in our area, and at the last meeting some of the administrators stated they used those codes more frequently than once every 3 years. Am I missing something?
A: You can bill outpatient consultations as many times as you want, as long as the definition of a consultation is met and documented each time.
The new regulations published by Medicare, that went into effect Jan. 1, 2006, stated the following: “If the consultant continues to care for the patient for the original condition following his or her initial consultation, repeat consultation services shall not be reported by this physician during his or her ongoing management of this condition. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation services. These services shall be reported as subsequent office visit (e.g., 99212 to 99215).”
If the patient hasn’t received ongoing management of the condition and the patient was not formally transferred to your care by the referring physician to handle this problem indefinitely, then you can again bill a consultation if another request is received for that same problem or a new problem.
In most cases where a primary care provider (PCP) sends you a patient, it is based on a limited number of visits and the PCP rarely transfers care to the dermatologist. Because of this, a consultation can be billed again if a new request for consultation is received. This is also the case with referrals from other primary care doctors or other specialists. The key points to consider are:
1. Has ongoing management of the patient occurred for the same condition?
2. Was the patient formally transferred to your care?
If you can answer “no” to both of these, then you can bill a consultation again and again as long as all the documentation criteria for a consultation have been met.
Lately, questions have been coming at me from left to right on a variety of topics. Although none of the questions in this month’s column have a single theme, hopefully, you will find information that will relate to your practice.
Q: I am working on my documentation for evaluation and management (E/M) visits. With respect to the History of Present Illness (HPI), I have this question: If a rash is described as “asymptomatic” in my chart note, does this fulfill the quality component of the history?
A: First of all, the quality factor of the HPI factors describes the character of the sign or the symptom. For example, if the rash was itchy, then the quality might be described as burning or stinging.
The most common HPI factors documented by dermatologists are usually, location, duration, signs and symptoms, and severity. Those four can meet the HPI factor requirement for any level of care; up to a level five.
So let’s assume that you are trying to determine if the patient’s rash or lesion is symptomatic (listed under signs and symptoms; not quality), it is not enough to simply state, “Asymptomatic.”
You need to document the questions you asked to which you got a negative response. For example, “Denies pain, itching, tenderness.” That would count for three HPI factors. Likewise, if the patient has a lesion, you might document, “Denies enlarging, getting darker, or bleeding.” Again, this would represent three HPI factors.
Q: I have a question about documenting the HPI factors for an E/M visit in the situation where I’m trying to determine the duration of a lesion, but the patient has stated that it is unknown (e.g., he or she can’t really remember how long the lesion has been present). In a case such as this, if I document “unknown duration”, does that count as an HPI factor under the duration part?
A: Yes it does, and that’s because you asked the question and documented the answer.
Q: When a patient comes to the office as the result of a consultation for a specific problem — let’s say a spot on the ear — can I only charge the consultation based on that one problem? Or, can I bill the level based on everything I found during the history and exam? I know that there are many new guidelines for consultations, and I certainly don’t want to overcode.
A: You meet the criteria for a consultation if first, you received a written request for it and noted the specific problem you were asked to provide advice and opinion on in your progress report. Also important is the fact that you send a letter of your findings.
The request for a consultation is not a request for the dermatologist to provide a certain level of care; it’s for advice or opinion on a specific problem. As the dermatologist, you also need to address any problems that the patient brings up during the visit and/or that you find during your examination. You then base the level of service on all that was done and documented; not just on the specific problem requested by the referring doctor.
Q: I am a dermatologic surgeon and hope that you can clarify an issue that seems to be the basis of dispute among myself and my partners, who are also all dermatologists. Here’s the specific scenario: A cancerous lesion is excised from the upper chest and I perform the repair. In order to accomplish that repair, I make cuts that go into the neck area. Can I select the repair code based on the neck (which pays more), or must I code based on the chest? This type of situation also frequently happens on the face, and the difference in payment can be quite significant.
A: That is a very good question.
You must code to the site of the skin cancer — not to where extensions are made in order to repair the site.
Q: I am a dermatopathologist and I read slides, not only for my specialty group of eight dermatologists, but also for other groups in the area. The group I’m with has never had a dermatopathologist before. Because I am very new to the group and new to billing (I am retired military), I just want to track my charges and make sure that my billing department is correctly coding and billing my services.
Here’s an example of the type of situation I come across: Yesterday, I received 14 bottles containing 14 lesions that were shave removed from a single patient. All of the lesions turned out to be benign intradermal nevi except for one lesion that was malignant. How should that claim be coded? (By the way we also make our own slides in-house.)
A: Since pathology services are not subject to the multiple surgery reduction rule, you should always bill these services in units on one line of the CMS 1500 form. Do this regardless of whether you bill globally (this means billing for both the technical and professional components), or just the professional component or only the technical component. In your case, you would bill 88305 on one line with 14 units indicated in block 24G of the old or new CMS-1500 claim form.
Your staff may make the argument that you can’t bill all of these components on the same line because one of the lesions has a different diagnosis. However, that doesn’t matter. As long as you have the correct diagnoses listed in the chart, or, in your case on the pathology reports, you just pick one of the covered diagnoses and link it to 24E of the claim form. You can list all the diagnoses in block 21, but only one diagnosis needs to be linked to a CPT code. If your staff would bill one of the 88305 on a separate line, it would be denied as a duplicate charge.
Q: How many years is it between using the consult codes (99241 to 99245) for an established patient? I thought it was 3 years, but I can’t seem to find the answer anywhere I’ve searched.
I belong to an office managers group in our area, and at the last meeting some of the administrators stated they used those codes more frequently than once every 3 years. Am I missing something?
A: You can bill outpatient consultations as many times as you want, as long as the definition of a consultation is met and documented each time.
The new regulations published by Medicare, that went into effect Jan. 1, 2006, stated the following: “If the consultant continues to care for the patient for the original condition following his or her initial consultation, repeat consultation services shall not be reported by this physician during his or her ongoing management of this condition. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation services. These services shall be reported as subsequent office visit (e.g., 99212 to 99215).”
If the patient hasn’t received ongoing management of the condition and the patient was not formally transferred to your care by the referring physician to handle this problem indefinitely, then you can again bill a consultation if another request is received for that same problem or a new problem.
In most cases where a primary care provider (PCP) sends you a patient, it is based on a limited number of visits and the PCP rarely transfers care to the dermatologist. Because of this, a consultation can be billed again if a new request for consultation is received. This is also the case with referrals from other primary care doctors or other specialists. The key points to consider are:
1. Has ongoing management of the patient occurred for the same condition?
2. Was the patient formally transferred to your care?
If you can answer “no” to both of these, then you can bill a consultation again and again as long as all the documentation criteria for a consultation have been met.
Lately, questions have been coming at me from left to right on a variety of topics. Although none of the questions in this month’s column have a single theme, hopefully, you will find information that will relate to your practice.
Q: I am working on my documentation for evaluation and management (E/M) visits. With respect to the History of Present Illness (HPI), I have this question: If a rash is described as “asymptomatic” in my chart note, does this fulfill the quality component of the history?
A: First of all, the quality factor of the HPI factors describes the character of the sign or the symptom. For example, if the rash was itchy, then the quality might be described as burning or stinging.
The most common HPI factors documented by dermatologists are usually, location, duration, signs and symptoms, and severity. Those four can meet the HPI factor requirement for any level of care; up to a level five.
So let’s assume that you are trying to determine if the patient’s rash or lesion is symptomatic (listed under signs and symptoms; not quality), it is not enough to simply state, “Asymptomatic.”
You need to document the questions you asked to which you got a negative response. For example, “Denies pain, itching, tenderness.” That would count for three HPI factors. Likewise, if the patient has a lesion, you might document, “Denies enlarging, getting darker, or bleeding.” Again, this would represent three HPI factors.
Q: I have a question about documenting the HPI factors for an E/M visit in the situation where I’m trying to determine the duration of a lesion, but the patient has stated that it is unknown (e.g., he or she can’t really remember how long the lesion has been present). In a case such as this, if I document “unknown duration”, does that count as an HPI factor under the duration part?
A: Yes it does, and that’s because you asked the question and documented the answer.
Q: When a patient comes to the office as the result of a consultation for a specific problem — let’s say a spot on the ear — can I only charge the consultation based on that one problem? Or, can I bill the level based on everything I found during the history and exam? I know that there are many new guidelines for consultations, and I certainly don’t want to overcode.
A: You meet the criteria for a consultation if first, you received a written request for it and noted the specific problem you were asked to provide advice and opinion on in your progress report. Also important is the fact that you send a letter of your findings.
The request for a consultation is not a request for the dermatologist to provide a certain level of care; it’s for advice or opinion on a specific problem. As the dermatologist, you also need to address any problems that the patient brings up during the visit and/or that you find during your examination. You then base the level of service on all that was done and documented; not just on the specific problem requested by the referring doctor.
Q: I am a dermatologic surgeon and hope that you can clarify an issue that seems to be the basis of dispute among myself and my partners, who are also all dermatologists. Here’s the specific scenario: A cancerous lesion is excised from the upper chest and I perform the repair. In order to accomplish that repair, I make cuts that go into the neck area. Can I select the repair code based on the neck (which pays more), or must I code based on the chest? This type of situation also frequently happens on the face, and the difference in payment can be quite significant.
A: That is a very good question.
You must code to the site of the skin cancer — not to where extensions are made in order to repair the site.
Q: I am a dermatopathologist and I read slides, not only for my specialty group of eight dermatologists, but also for other groups in the area. The group I’m with has never had a dermatopathologist before. Because I am very new to the group and new to billing (I am retired military), I just want to track my charges and make sure that my billing department is correctly coding and billing my services.
Here’s an example of the type of situation I come across: Yesterday, I received 14 bottles containing 14 lesions that were shave removed from a single patient. All of the lesions turned out to be benign intradermal nevi except for one lesion that was malignant. How should that claim be coded? (By the way we also make our own slides in-house.)
A: Since pathology services are not subject to the multiple surgery reduction rule, you should always bill these services in units on one line of the CMS 1500 form. Do this regardless of whether you bill globally (this means billing for both the technical and professional components), or just the professional component or only the technical component. In your case, you would bill 88305 on one line with 14 units indicated in block 24G of the old or new CMS-1500 claim form.
Your staff may make the argument that you can’t bill all of these components on the same line because one of the lesions has a different diagnosis. However, that doesn’t matter. As long as you have the correct diagnoses listed in the chart, or, in your case on the pathology reports, you just pick one of the covered diagnoses and link it to 24E of the claim form. You can list all the diagnoses in block 21, but only one diagnosis needs to be linked to a CPT code. If your staff would bill one of the 88305 on a separate line, it would be denied as a duplicate charge.
Q: How many years is it between using the consult codes (99241 to 99245) for an established patient? I thought it was 3 years, but I can’t seem to find the answer anywhere I’ve searched.
I belong to an office managers group in our area, and at the last meeting some of the administrators stated they used those codes more frequently than once every 3 years. Am I missing something?
A: You can bill outpatient consultations as many times as you want, as long as the definition of a consultation is met and documented each time.
The new regulations published by Medicare, that went into effect Jan. 1, 2006, stated the following: “If the consultant continues to care for the patient for the original condition following his or her initial consultation, repeat consultation services shall not be reported by this physician during his or her ongoing management of this condition. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation services. These services shall be reported as subsequent office visit (e.g., 99212 to 99215).”
If the patient hasn’t received ongoing management of the condition and the patient was not formally transferred to your care by the referring physician to handle this problem indefinitely, then you can again bill a consultation if another request is received for that same problem or a new problem.
In most cases where a primary care provider (PCP) sends you a patient, it is based on a limited number of visits and the PCP rarely transfers care to the dermatologist. Because of this, a consultation can be billed again if a new request for consultation is received. This is also the case with referrals from other primary care doctors or other specialists. The key points to consider are:
1. Has ongoing management of the patient occurred for the same condition?
2. Was the patient formally transferred to your care?
If you can answer “no” to both of these, then you can bill a consultation again and again as long as all the documentation criteria for a consultation have been met.
