In September's issue, I shared some coding challenges with you. I heard from PAs across the country, and the sentiment was the same: Why do we know so little about something so important? After all, we have two reasons to be current on coding and documentation guidelines. The first and most important reason is that compliance is the law, and as a PA you are ultimately responsible for what gets billed under your provider number. The second reason is that knowing and abiding by the rules and knowing how to ethically maximize reimbursement for your services will make you more valuable in today's job market.
Here are some more coding challenges and a test of your evaluation and management (E/M) coding skills.
Challenge No. 1
A 67-year-old patient with Medicare insurance is seen in a family practice office for a head injury and laceration. The physician evaluates and manages the head injury and then is called out of the office for an emergency obstetric delivery. The PA steps in and sutures the laceration. How should this be billed?
Challenge No. 2
A 40-year-old established patient complaining of severe vertigo, nausea and vomiting comes into your office. You take a history and perform a physical examination. You determine that she is dehydrated. You start an IV of normal saline and give her 50 mg of hydroxyzine pamoate (Vistaril) intramuscularly for the nausea. She is in your office for a total of 90 minutes, but you document a total of 30 minutes face-to-face contact with the patient. How should you code for this encounter?
Challenge No. 3
You perform a shave biopsy on a suspicious skin lesion. You then see the patient three days later for a wound check. How is this coded differently than if you had done an excision of the lesion?
Challenge No. 4
History: A 90-year-old established patient on Coumadin therapy for atrial fibrillation comes to your office for prothrombin time/International Normalized Ratio. You are the only provider in the office.
Medical decision-making: The medical assistant reports to you that the result of the PT/INR is 3.2. You lower the dose slightly and order another test in a week. That information is communicated through the medical assistant, but you never actually see the patient. How would you code and bill for this situation?
Challenge No. 5
Chief complaint: A 16-year-old established patient with a history of insulin-dependent diabetes mellitus comes to your office complaining of a sore throat, a fever and swollen glands.
History of present illness: Her symptoms have progressed over the last 48 hours. Acetaminophen makes no difference. The patient is fatigued and has no appetite. Her blood sugars have been running high, in the 180 to 220 mg/dL range, for the last two days.
Review of symptoms: Fatigue, decreased appetite; no cough or shortness of breath; no nausea, vomiting or diarrhea.
Medications: NPH insulin, 20 units in the morning, 35 units in the evening. Regular insulin, 10 units b.i.d. and on sliding scale.
Allergies: None.
Social history: Nonsmoker; denies alcohol use.
Physical examination: Her pulse is 80 beats per minute, her blood pressure is 122/70 mmHg, her respiratory rate is 16 per minute and her temperature is 101 degrees. She appears tired. HEENT examination shows a red throat with exudates and a supple neck with large anterior cervical nodes. No other lymphadenopathy is present. The lungs are clear. Heart auscultation reveals no murmurs, rubs or gallops. Her abdomen is soft and nontender with no hepatosplenomegaly.
Laboratory: A rapid strep test is negative.
Medical decision-making: For the pharyngitis/lymphadenopathy, you check backup throat culture, complete blood count and heterophils to rule out mononucleosis. You withhold antibiotics until the throat culture returns. You advise fluids, rest and avoiding contact sports until the mono test result is back. For the diabetes, you determine her poor control is related to infection; you increase the sliding scale to accommodate high glucose levels during infection and plan to monitor her closely for hypoglycemia as the infection clears.
What level would you assign this visit and why?
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Answer to Challenge No. 1
The office visit would be billed under the physician's PIN with a modifier 25 (which indicates a separate, identifiable service). The wound repair would be billed under the PA's PIN.
Answer to Challenge No. 2
First, code the E/M service according to your documentation. You can also use code 90780 for the hour of IV therapy. Code the Vistaril and the administration (although this will be bundled into the E/M code by most payers). This visit is not eligible for prolonged service codes for two reasons. First, the face-to-face time must be at least 30 minutes over the time allotted for the E/M code. Even if you code 99214, which carries an average of 25 minutes, you would have to document 55 total minutes of face-to-face time with the patient. Second, CPT rules state that you cannot bill the IV administration codes with prolonged service codes.
Answer to Challenge No. 3
A shave biopsy is a starred procedure, meaning that many carriers will allow follow-up visits. The excisional codes carry a 10-day global period. This means that routine follow-ups for the procedure are bundled into the original payment for the procedure.
Answer to Challenge No. 4
A medical assistant may bill 99211 as "incident to" a PA's services. Incident-to billing would be appropriate in this case.
Answer to Challenge No. 5
You have chief complaint, four elements of a history of present illness, a review of systems with six components in three systems, a social history, a physical examination with six systems examined, and medical-decision making of moderate complexity due to the associated diabetes and potential complications. You have all the elements of the history and medical decision making to justify code 99214. This is an established patient, so only two of three elements (history, examination, medical decision-making) are needed. If this were a new patient, three of three elements would be needed, and a 99203 would be coded.
Learning and applying E/M documentation guidelines can be the most difficult task for a provider. Work together with billing personnel and perform self-audits to be sure you are staying compliant.
This article originally appeared in the Sept. 2001 issue of ADVANCE for Physician Assistants.
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