The Art of the Science of Coding

It would be hard to imagine a situation where coding, which has ramifications in reimbursement and compliance, could be "under-explained" without potentially affecting both reimbursement and compliance. For that reason we will limit our content to a couple of key coding-related items that, in our experience, seem to cause a lot of confusion and questions.

Compliance and Documentation

In matters of coding, first and foremost, compliance must be taken into account. Two key phrases among coders are these: "If it wasn't documented, it didn't happen," and "If the documentation isn't legible, it didn't happen." The principles of documentation are applicable to all types of medical and surgical services in all settings. The medical record should be complete and legible. The documentation of each patient encounter should include the following: reason for the encounter and relevant history; physical examination findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer.

Inappropriate Coding of Consultations Instead of New Patient Visits

It is important to differentiate between a new patient visit and a consultation. When seeing a new patient to determine if it is a consultation or a new patient visit, we need to know the intent of the referring physician; if it is to transfer care, then you would bill for the visit as a new patient visit and not a consultation. If it is an established patient, bill as an established patient. The exception to this is that if a physician is requesting your opinion on something and you are only rendering an opinion for a new condition, you can bill as a consultation.

Requirements for Consultations

Your dictation should include the fact that the doctor requested you see the patient (i.e., Dr. "X" has requested that I see Patient "Jane Doe" for the following reasons). It should have your results or opinion, and it should have a statement that a letter has been sent back to the referring doctor, with a copy of the letter in the chart. A simple way to think of this is the three Rs of consultations:

1. request (by another provider)
2. render (opinion)
3. response (written report)

If or when the patient returns to you for care, they are now an established patient and not a follow-up consultation unless a doctor requests your opinion for something else. An outpatient consultation code can be billed for the outpatient hospital or emergency room (you should not bill the ER codes unless you are the ER doctor). If you are called in, you should use consultation codes.

Now that you know what a consultation "is" and when to use it, for purposes of differentiation, here are examples of what a consultation "is not":

• a standing order in the medical record for consultations
• a consultation done without a specific request
• no written report of a consultation sent to the requesting physician
• providing care for own patient on an emergency basis

Proper Use of Modifiers

A modifier is added to a CPT code to show that a service has been modified in its identification or definition. A common use of modifiers is to explain special circumstances or conditions, or to indicate repeat or multiple procedures. It is important to note that not all modifiers can be used with every CPT code. Space and time prohibit reviewing all modifiers, so we would like to focus on a common mistake or misconception many people have in the use of two modifiers: 25 and 57.

Per CPT, modifier 25 is a "significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service." It "indicates the patient's condition required a significant, separately identifiable E&M service be performed above and beyond the other service provided." A good standard for determining whether the 25 modifier should be used is this: documented, extra pre-op and/or post-op work beyond what is usually performed with a minor procedure/surgical service. The physician must determine if the E&M service for which he or she is billing is distinct from the procedure/surgical service. An example of this would be an E&M visit that resulted in a decision to perform a procedure or minor surgery.

Per CPT, modifier 57 is "decision for surgery." "(It is) an E&M service that resulted in the initial decision to perform the surgery. This modifier is used to report an E&M service that resulted in a decision to perform a major surgical procedure on the day of or the day before the surgery." An E&M service provided the day before or the day of a major surgery that resulted in the initial decision to perform that surgery may be eligible for reimbursement when modifier 57 is appended to the E&M code. A major surgery is defined as having a 90-day global period as assigned by Centers for Medicaid and Medicare Services (CMS).

Modifier 57 is not valid for use when the E&M service is associated with a minor surgical procedure (defined as having a zero- or 10-day global period as assigned by CMS). Because the decision to perform a minor procedure is typically done immediately before the service, it is considered a routine preoperative service and therefore not separately reimbursable.

Modifier 57 is not valid for use when the E&M service was for the preoperative evaluation.

General Modifier Tips

• Always have the most recent edition of the CPT book on hand.
• Have your billing staff attend coding workshops.
• Learn about using modifiers so you can help your billing staff with coding questions.