Coding Consult

History of UTIs

Q. A female patient who's had multiple previous UTIs presented with a complaint of burning when urinating. Although the urinalysis came back negative, I prescribed antibiotic treatment because of her history. What should I use as the diagnosis code?

Q. Should I report an office visit in addition to a repeat Pap test?

A. That depends. A visit for a repeat Pap test often involves more than just the procedure. You may end up discussing the patient's current health status or answer questions she raises. In this case, report the office visit, such as 99212 (office or other outpatient visit for an established patient . . .). To indicate that the service is significant and separate from the Pap smear collection, append modifier –25 to the E&M service and provide documentation. Link 99212–25 to 795.08 (unsatisfactory smear).

But if the patient returns for a "re-Pap" due to an unsatisfactory smear and you don't perform an additional service, code only for the collection. To Medicare and other carriers that recognize the HCPCS Pap smear code, report Q0091 (screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory). Indicate a repeat Pap smear by attaching modifier –76 (repeat procedure by same physician) to Q0091. Otherwise, use 99000 (handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). Report Q0091–76 or 99000 with either V76.2 (special screening for malignant neoplasms, cervix), V76.47 (. . . vagina), or V76.49 (. . . other sites).

Same-day discharge and admission

Q. When I discharge a patient from the hospital and immediately admit him to a nursing facility, should I code both services?

A. Yes. "Hospital discharge services performed on the same date of nursing facility admission or readmission may be reported separately," according to CPT's "Initial Nursing Facility Care" introductory notes.

You must document the hospital discharge (99238-99239, hospital discharge day management . . . ) and nursing facility admission (99304–99306, initial nursing facility care, per day, for the evaluation and management of a patient . . . ) as two distinct services. Each set of codes requires different elements.

For instance, hospital discharge codes "include, as appropriate, final examination of the patient, discussion of the hospital stay . . . instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms," according to CPT's notes on "Hospital Discharge Services."

On the other hand, initial nursing facility care code 99304 requires a detailed or comprehensive history and examination, and straightforward or low-complexity medical decision-making.

Be aware that CPT doesn't permit you to code a same-day nursing home discharge and a hospital admission.

This information is adapted from material provided by the Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact the Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592 or visit http://www.codinginstitute.com.