Hint: Just because your doctor visits the ICU doesn’t mean he can report critical care.

Most medical practices report outpatient E/M codes (99201-99215) every day, but some Part B providers are still falling victim to several of the most common E/M myths. Button up your coding processes by dispelling these three commonly-held misunderstandings.

Myth 1: When reporting 99211 “incident to” a physician, you should bill it under the name of the physician on record for that patient.

Reality: When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician’s name. The OIG recently found that many practices are billing incident to services under a physician’s name who was not on the premises during the encounter. Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. “Incident to” requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.

Myth 2: If a patient has symptoms of a particular illness, you can count that information toward both the history of present illness (HPI) and review of systems (ROS).

Reality: You can’t “double dip” and count the same information toward two separate elements.

Example: If the patient suffered a sprain or fracture, the doctor would typically address the musculoskeletal system during a ROS. Examples of a musculoskeletal ROS might include symptoms such as poor range of motion, joint pain, dislocation, or muscle stiffness, among others. These can be...

Be sure your coding complies with ICD-9 official guidelines for pain management.

If you don’t know when to check ICD-9 official guidelines, you may have just a 50-50 chance of choosing the proper order for your diagnosis codes.

Case in point: Patients may present to the office for treatment related to pain caused by a neoplasm. In such cases, you will need to determine, which diagnosis codes to report, and you will need to decide what order to list the codes in on your claim. With that in mind, consider how you should code the scenario below.

Start by Examining the Neoplasm-Related Pain Case

Read the following scenario and determine proper ICD-9 coding based on the information given. You’ll find a helpful hint on which section of the official guidelines to review if you get stuck.

Scenario: The physician documents that a patient with lung cancer (middle lobe, primary malignant neoplasm) presented to the office for the purpose of pain management. The pain is documented as acute and caused by the neoplasm.

Hint: See section I.C.6.a.5 of the Official Guidelines for instructions on properly coding these sorts of encounters. The CDC posts ICD-9 guidelines online at: www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

Next, Determine Which Neoplasm and Pain Codes Apply

For this scenario, before you can decide what order to put the codes in, you will need to decide which codes to report.

Neoplasm: For a primary malignant neoplasm of the lung’s middle lobe, you should report 162.4 (Malignant neoplasm of middle lobe bronchus or lung), says Denae M. Merrill, CPC, HCC coding specialist in Michigan.

Pain: To choose the proper pain diagnosis code, you want to be sure you keep in mind that the neoplasm is the cause. The ICD-9 index entry for pain has several subentries to consider:

• Cancer associated
• Neoplasm

...

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?

<Answer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management service that diagnosed the fracture and led to the decision to treat it.
• 27810 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation) for the fracture care
• 73600 (Radiologic examination, ankle; 2 views) x 2 for the x-rays (one before the surgery, and one to ensure proper bone placement postsurgery)
• 824.4 (Fracture of ankle; bimalleolar, closed) appended to 99203, 27810, and 73600 to represent the patient’s ankle fracture
• E016.X (Activities involving property and land maintenance, building and construction) appended to 99203, 27810, and 73600 to represent the cause of the patient’s ankle fracture. The nature of the “yard work” that the patient was doing will determine the appropriate last digit of this code.

Modifier alert: Be sure to check with your payer before filing this...

Verify evidence of previous treatments for successful claims.

If you’re coding for a patient’s carpal tunnel syndrome (CTS) injection, double check for previous, less invasive CTS treatments before getting too far with your claim. If the physician administers an injection during the patient’s initial visit for CTS, you could be facing a denial. Some payers allow CTS injection therapy only when other treatments have failed. Check out these FAQs to make each CTS coding scenario a snap.

Should the Physician Try Other Treatments Before 20526?

Yes. The FP would likely try less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. These treatments might include, but are not limited to:

• splinting (or bracing)
• medication (non-steroidal anti-inflammatory)
• occupational therapy.

If the patient’s symptoms don’t improve after these attempts, the physician may then proceed with a corticosteroid injection of the carpal tunnel, Hammer says.

Caveat: Check with the payer if you are unsure of its “previous treatment” requirements. Even evidence of previous treatments might not be enough to convince some insurers, says Jacqui Jones, a physician office manager in Klamath Falls, Ore. “We have had a couple of contracted HMOs [health maintenance organizations] impose conservative nonsurgical treatment – even with previous treatment and positive nerve conduction velocities ordered by another physician,” says Jones.

What Diagnoses Support Carpal Tunnel?

Patients that become candidates for CTS injections may present initially with “complaints of progressively worse numbness and tingling (782.0, Disturbance of skin sensation) in their hand and wrist, particularly the thumb, index, and middle finger,” Hammer explains. As the CTS...