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administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required. 99211 Most Abused Code Nationwide, 99211 is one of the most abused codes for usage. Code 99211 describes a service provided for minimal problems that may not require the presence of a physician, but does require the presence of a patient. As stated previously, this code cannot be billed if only an injection is given, without documented pertinent questioning or instructions. It cannot be billed for: • telephone calls, • venipunctures, • prescription renewals to a pharmacy, • telephone calls for a patient to reschedule an appointment, and • telephone calls with the results of laboratory testing. Billing 99211 is not allowed for every patient who enters the office for a minimal service and receives an unnecessary pulse, temperature, or blood pressure recording. Prothrombin Time and Evaluation of Patient Anti-Coagulation Status - CPT Code 99211 The following was developed from consultation among Medicare Part B Contractor Medical Directors and review of the CMS Frequently Asked Questions Web site. The CPT code description for 99211 follows: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. When a face-to-face medication management is provided by qualified office staff on the same date of the laboratory test, the physician may bill CPT code 99211 if the services are medically necessary and constitute a distinct, separately identifiable evaluation and management (E/M) service that is consistent with the criteria for a low-level office visit. The following describes adequate documentation for CPT code 99211 when billed for an evaluation of a chronically anti-coagulated patient for whom a prothrombin time has been drawn and determined. Reason for the visit - A physician visit is not routinely necessary in order to draw blood for prothrombin time or other laboratory tests. Therefore, the documentation for 99211 or any other E/M code in this circumstance must demonstrate a need for clinical evaluation and management. In this case, services that would serve to demonstrate that evaluation and management were performed include evaluation of significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who have no new clinical concerns, demonstrating how the relevant laboratory information obtained was used to modify therapy will document that a separately payable E/M service has been performed. • Current medications listed (with notation of level of compliance) • Indication of physician’s evaluation of the information about signs/symptoms and laboratory test result and his or her management recommendation • Identity and credentials of provider(s) as listed in text above If the patient does not have any new symptoms or requires a change in the dosage of his/her medication, the physician cannot report 99211. 5-28 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
HOSPITAL OBSERVATION SERVICES – CPT CODES 99217-99220 Medicare Claims Processing Manual Chapter 12 §30.6.8 (Codes 99217 99220) (Rev. 1, 10-01-03) B3- 15504 A. Who May Bill Initial Observation Care Carriers pay for initial observation care billed by only the physician who admitted the patient to hospital observation and was responsible for the patient during his/her stay in observation. A physician who does not have inpatient admitting privileges but who is authorized to admit a patient to observation status may bill these codes. For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter. Payment for an initial observation care code is for all the care rendered by the admitting physician on the date the patient was admitted to observation. All other physicians who see the patient while he or she is in observation must bill the office and other outpatient service codes or outpatient consultation codes as appropriate when they provide services to the patient. For example, if an internist admits a patient to observation and asks an allergist for a consultation on the patient’s condition, only the internist may bill the initial observation care code. The allergist must bill using the outpatient consultation code that best represents the services he or she provided. The allergist cannot bill an inpatient consultation since the patient was not a hospital inpatient. B. Physician Billing for Observation Care Following Admission to Observation If the patient is discharged on the same date as admission to observation, Carriers pay only the initial observation care code because that code represents a full day of care. If the patient remains in observation after the first date following the admission to observation, it is expected that the patient would be discharged on that second calendar date. The physician bills CPT code 99217 for observation care discharge services provided on the second date. In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital. C. Admission to Inpatient Status from Observation If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill an initial observation care code for services on the date that he or she admits the patient to inpatient status. If the patient is admitted to inpatient status from observation subsequent to the date of admission to observation, the physician must bill an initial hospital visit for the services provided on that date. The physician may not bill the hospital observation discharge management code (code 99217) or an outpatient/office visit for the care provided in observation on the date of admission to inpatient status. 5-29 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27: service or other face-to-face servi
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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