Please note that University Physicians, Inc. is now doing business as University of Colorado Medicine (or "CU Medicine").
HomeDepartmentsAudit, Compliance & Education (ACE)
Also in this Section

ACE Coding FAQ's

Created: 06/05/2015 | Updated:  

1.We have a Medicare patient who presented to the ER with a post op infection during the global period of his surgical procedure. Our physician was called to the ER to see this patient and submitted charges for the I&D he performed in the ER. I am not sure if we can report these services. Is this I&D separately reportable or not?
2. If an inpatient in an acute care hospital is transferred to my services and it is the initial time for me to see the patient, can I bill an "Initial hospital care " code (99221 - 99223)?
3. If I see a patient in my clinic and determine to directly admit this patient to the hospital, then turn this patient over to our departments "hospitalist", can I bill the clinic visit and the "hospitalist" bill the admit code?
4. If I see an established patient in my clinic and document a low level evaluation and management service (E/M 99213) but spend a total of 45 minutes with the patient discussing various aspects of his/her care, how can I bill for my services?
5. What documentation is required for level of service for 99204, 99205 and 99244, 99245?
6. When is it appropriate to include a time component for patient documentation? When the majority of your visit is spent in counseling or coordination of care, it is important to include time in your note.
7. What about Critical care documentation? What is required to support Critical Care?
8. Are hospital discharge service codes based on time?
9. Please clarify documenting History for E/M visits.
10. How do I appropriately use four of the most commonly used modifiers?  (Modifier 25, Modifier 59, Modifier 76 and Modifier 77)
________________________________________________________________________________________________________________________


1.We have a Medicare patient who presented to the ER with a post op infection during the global period of his surgical procedure. Our physician was called to the ER to see this patient and submitted charges for the I&D he performed in the ER. I am not sure if we can report these services. Is this I&D separately reportable or not?


No, the service is not separately billable according to Medicare's definition of the global surgical package. To bill for treatment of a complication during the global period, the service must be performed in the OR, ASC, endoscopy/laser suite, or ICU if the patient is critically ill and is unable to be transported to the OR. The ER, holding area, PAR, non-certified procedure room does not constitute an approved location.

2. If an inpatient in an acute care hospital is transferred to my services and it is the initial time for me to see the patient, can I bill an "Initial hospital care " code (99221 - 99223)?

No. According to the guidelines these codes are "used to report the first hospital inpatient encounter by the admitting physician". For initial inpatient encounters by physicians other than the admitting physician, when a patient is referred to their service, one would use a subsequent hospital care code - 99231-99233.

3. If I see a patient in my clinic and determine to directly admit this patient to the hospital, then turn this patient over to our departments "hospitalist", can I bill the clinic visit and the "hospitalist" bill the admit code?

No, not if you and the "hospitalist" are of the same group and same specialty only one provider can bill. You would bill a clinic visit or roll your visit into an admit to be bill by yourself or the "hospitalist."

4. If I see an established patient in my clinic and document a low level evaluation and management service (E/M 99213) but spend a total of 45 minutes with the patient discussing various aspects of his/her care, how can I bill for my services?


You have two options:
     • First option is you could bill according to the counseling and coordination of care rules for E/M services if you document the total amount of time spent with the patient plus stating that more than 50% of the time was counseling and        document an overview of what was discussed you can bill according to total time - 99215 = 40 minutes or more.
     • Second option - You could bill your level of service according to documentation, 99213 PLUS since you stated you spent a total of 45 minutes with the patient and CPT 99213 is approximately 15 minutes duration, you spent an additional 30 minutes with the patient. You would use an additional add-on code for prolonged time 99354 for the 30 minutes or more of documented prolonged time spent with the patient.

5. What documentation is required for level of service for 99204, 99205 and 99244, 99245?


Documentation for level of service for new patients and consultations is the same - all above listed codes are comprehensive level. The difference between level 4 and 5 of new patients or consultations is found within the decision making.
To bill a new patient or consultation all three areas of history, examination and decision making must meet or exceed minimum requirement as stated below:
History :
     • Four or more elements of history of present illness or 3 or more multiple chronic conditions (that you are addressing or affects your services)
     • Complete review of systems (ROS) which includes 10 systems or some pertinent systems with the statement "all others negative". A patient history form filled out by the patient or his/her representative or other qualified person, may be reviewed, signed and referred to by the billing provider for a complete review of systems.
     • At least one statement from each of the past medical, family, and social history areas. The Family History is the main area lacking in physician documentation resulting in lower levels of service being billed.

Examination: According to the 1995 documentation guidelines (for specialty specific 1997 guidelines see the UPI Orange Booklet)
     • Eight or more systems must be documented. The organ systems include; 1) constitutional, 2) eyes, 3) ears, nose, mouth, throat, 4)cardiovascular, 5) respiratory, 6) gastrointestinal 7) genitourinary, 8) musculoskeletal 9) skin, 10) Neurological 11) psychological 12) Hem/lymph/immuno.

Decision Making: Level 4 decision making is moderate complexity while level 5 is high complexity. A high complexity could present as a new problem to provider with additional workup planned along with review and/or ordering of lab, radiology and/or other tests in the medicine section of CPT along with reviewing of old records or discussing case with other health care providers. Additionally high complexity should include a patient with one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or cardiac electrophysiological tests, diagnostic endoscopies with identified risk factors, major surgery with risk factors, or drug therapy requiring intensive monitoring for toxicity. Level 5 should be reserved for your most complex patients that require complex management of multiple conditions or risk to life decisions or procedures.


6. When is it appropriate to include a time component for patient documentation? When the majority of your visit is spent in counseling or coordination of care, it is important to include time in your note.

Counseling & Coordination of care:
     • Greater than 50% of visit is spent Counseling &/or Coordinating care. This is only for the Attending’s time spent with the patient/family. A Resident may not document the time on the Attending’s behalf.
     • For Outpatient visits, the time must be face to face with the patient.
     •For Inpatient visits, the time may be provided at the patient’s bedside or on the hospital floor/unit.
     •The total time of the visit & the total time spent Counseling &/or Coordinating care must be documented.
     •There must be a summary of the discussion documented in the note. **Additionally: When it is stated “see my note above for details/summary”, it needs to be very clear within the note what you discussed with the patient. If it is not clear, your documentation may not support the level billed.



7. What about Critical care documentation? What is required to support Critical Care?

Time Based Critical Care: •Code 99291 should be used to report the services of a physician providing constant attention to a critically ill and unstable patient for a total of 30 to 74 minutes on a given day.
     • Code 99292 should be used to report the services of a physician providing constant attention to the critically ill and unstable patient for 30 minutes beyond the first hour and 14 minutes of critical care on a given day, i.e., providing a total of between 75 and 104 minutes. This code may be used to bill subsequent periods of 30 minutes on the same day.
     • When multiple providers are billing for critical care on the same day the actual time spent on the patient should be documented.
     •When using a Residents note, the Attending must document the following for the above codes: ?The time the teaching physician spent providing critical care.
          ?That the patient was critically ill during the time the teaching physician saw the patient.
          ?What made the patient critically ill.
          ?The nature of the treatment and management provided by the teaching physician.

8. Are hospital discharge service codes based on time?

Yes, for hospital discharge coding a provider should document the following;
     •Document the total duration of time spent by a billable physician for final hospital discharge.
     •The time spent by the billing physician on the final day of discharge does not have to be continuous.
     •Includes, as appropriate, final examination, discussion of the hospital stay, instructions for continuing care to all relevant         caregivers, preparation of discharge records, prescriptions and referral forms.

9. Please clarify documenting History for E/M visits:
     • The verbiage “None” or “Not on file” is not acceptable, and will not count as billing credit for any part of the PFSH.
     • The verbiage “Non-contributory” or “Not-pertinent” will be acceptable for Family History only. However, the provider should be educated that the recommendation is to document what the family history non-contributory or not pertinent is for (e.g., Family history non-pertinent/non-contributory for heart disease for a patient complaining of chest pain.)
     • If the provider is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining history (if this is documented, this will count as billing credit towards a comprehensive history).
     • If the provider is referencing a past note for ROS and/or PFSH, the note does not necessarily have to state the date of the note they are referencing. However, the documentation should direct you to the past note. If it is not clear, you may query the provider for clarification.
 
10. How do I appropriately use four of the most commonly used modifiers? (Modifier 25, Modifier 59, Modifier 76 and Modifier 77)
Click Here