Coding and Documentation: A Brief Guide

Dipesh Navsaria, MPH, PA-C


September 12, 2001

In This Article

Some Coding Fine Points

Nursing Visits

In general, the provider cannot charge an established patient for a minimal visit -- these are considered nursing visits only. For example, someone who comes in for a TB test which is performed by the nurse without physician consultation will be billed at level I. However, if that patient tells the nurse he's had tuberculosis in the past and the physician is called into the room to further evaluate the patient, the visit becomes at least a level II.

A new patient is someone who has not been seen by you or someone in your group of the same specialty within the last 3 years. Thus, a patient who usually sees family practitioner Dr. Smith comes in 1 month later to see family practitioner Dr. Jones is not considered a new patient. Other examples include:

  • An established patient who has not bee seen within 5 years is considered a new patient.

  • If a patient is referred to a specialist (eg, an endocrinologist) by a member of the same group in a different specialty, that patient is a new patient for the referred physician.

  • If covering for a physician who is of the same specialty but not in the same group, his or her patients are considered new patients on their first visit to the covering physician.

There are a set of codes called consultation codes that are used when a patient is referred to you by someone else. These are generally reimbursed at a higher rate, however, the referred physician is required to report back to the referring source (a written letter or copy of your note generally suffices) in order to charge this code. If the referred physician assumes care of the referred patient, subsequent visits fall under the usual E&M codes. Keep in mind that the referring source doesn't necessarily need to be another health care provider -- eg, a school could refer (with parental consent) a child with behavior problems.

A common misconception is that downcoding, can help avoid audits. Unfortunately, not only is this not true, it also cheats the physician out of legally and ethically entitled revenue. Certainly a primary care provider charging level V visits a high percentage of the time will probably flag an audit, but never charging a level V only ends up harming you. Some insurers (especially the federal government) will target providers with an unusually high level of level II-III visits on the grounds that physicians can illegally profit by having patients come back unnecessarily for multiple short visits.

Some providers don't charge using new CPT codes that are introduced on the grounds that "insurance doesn't pay for it anyhow." This attitude can ultimately limit coverage. For example, if no one charges the CPT code for vision screening at well-child checkups, then insurance companies will be less likely to cover it. Look at the procedure code, and assess the impact on your patients and your budget before deciding to use or forgo it.

A very common question is what to do when a patient shows up for a physical but has another problem that needs evaluation. Certainly, if it's a minor problem, or something that would be considered part of preventive medicine, the diagnosis may be listed but the CPT code is the same. What if a significant problem is detected? It's not particularly fair that the patient with no problems is billed the same amount as the person seen on the same day whose physical detects depression, which is a condition that can be charged as a level IV. In this case, use the "-25" modifier. This modifier tells insurers that a "significant, separately identifiable service" was provided on the same day as another service. So, in the above example, the CPT code for the physical would be billed as well as CPT 99214-25. You won't get paid as much as you might for a full level IV (or, for that matter, get paid anything extra), but this method can often result in an increased payment. Of course, if the detected condition is something that can legitimately wait, it may be worth it to have the patient return for a specific evaluation.

Check to see what sort of impact your coding will have on your patients. In many cases, if a particular code is not paid for, the charge will simply be passed on to the patient. Charging a particular CPT code or "-25" modifier may be justified, however, it could be problematic if a large proportion of your practice complains about being responsible for these charges.

The codes are considered universal in that a visit for diagnosis and treatment of pneumonia in rural Wisconsin should be coded the same way as the same visit in New York City. The codes may be reimbursed at markedly different rates in different areas, but the codes themselves should be consistent.