Coding Cues

Key Points

A pre-op visit

A surgeon requested that I see a patient to give him preoperative clearance. How should I code the visit?

If you document the surgeon's request and the reason for the exam, evaluate the patient, and give the surgeon a written report, you could use an appropriate consultation code based on the level of service and where you saw the patient: your office (99241-99245) or the hospital (99251-99255). Select a diagnosis code from the V72.81-V72.84 series for a pre-op exam and also choose a code for the condition that prompted the surgery. You should also code any diagnoses that you find during your exam.

If the service you're providing doesn't meet the requirements for a consultation, choose another appropriate E&M code. You could be reimbursed as long as your records support that the pre-op exam's medically necessary and you meet the other requirements for the service you submit.

Two same-day hospital visits

I examined a patient who'd been hospitalized with breathing problems and intended to report 99231 (subsequent hospital care, per day . . .) for the visit. But later that day, I returned to the hospital because she went into respiratory arrest and I provided an hour of critical care. How should I submit these services?

In this case, you can report both a critical care code and the subsequent hospital care code. Use 99291 to report the critical care service; that code is used to report the first 30 to 74 minutes of critical care. Link it to 799.1 (respiratory arrest). Also submit 99231 with modifier –25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the critical care and E&M were separate services.

Remember that critical care services are time based, and you must document the time you spend providing this service. The medical record must also support that the two visits were separate and medically necessary.

Digital rectal exams

I've gotten reimbursed from Medicare before for digital rectal exams when they're part of prostate cancer screening. But when I bill G0102 (prostate cancer screening; digital rectal examination) with an E&M service and modifier –25 (significant, separately identifiable E&M service . . .) the DRE is denied. How come? Is there something that I can do?

The reimbursement for G0102 is bundled into the payment for a covered E&M service (99201-99499) when the two services are furnished to a patient on the same day. Adding modifier –25 won't allow you to be paid for the screening separately. But if the DRE is the only service, or is done as part of a noncovered service, such as a preventive exam, G0102 is payable separately if all Medicare coverage requirements are met.

Medicare covers a DRE annually for beneficiaries age 50 and older. After receiving the first screening, he may get another after 11 full months have passed. So if you see a patient for, say, an annual exam and you perform a DRE, you can bill G0102 to Medicare and get paid, as long as it's been 11 full months since his last test. Use diagnosis code V76.44 (special screening for malignant neoplasms; prostate).