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Date of Service
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Question:
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Answer:
The correct date of service is the actual date of service when the attending physician saw the patient. In this case, it will be Wednesday even if the attending physician links the note to the resident note from the previous date.
*This response is based on the best information available as of 3/28/24.
Diagnosis Coding Excludes 1 Codes
Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.
Question:
Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.
Answer:
No, we should never change anything in the provider documentation or remove information from the provider’s assessment and plan. Great news to hear you are reviewing your claims edit reports timely and it appears your edit is set up correctly in your system. The “Excludes 1” is an ICD-10 coding guideline or a coding rule found in the Conventions for the ICD-10-CM. A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE”. An Excludes 1 indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. For the complete information and definition of Excludes Notes please refer to Section 1A Conventions for the ICD-10-CM #12.
*This response is based on the best information available as of 3/14/24.
DME Billing Inquiry
With Medicare, some of our patients come in on a different day other than the office visit to pick up their DME. Do we use the date they pick up the DME item or the date of the office visit for billing?
Question:
With Medicare, some of our patients come in on a different day other than the office visit to pick up their DME. Do we use the date they pick up the DME item or the date of the office visit for billing?
Answer:
The date of service for billing in this instance would be the date the DME is picked up (date of delivery to the patient).
*This response is based on the best information available as of 2/29/24.
DME Billing Inquiry
Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?
Question:
Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?
Answer:
Medicare Advantage Plans are required to cover what Medicare covers at a minimum. You should reach out to the individual plan and inform them of this. You can also attach the Medicare coverage policy when you appeal the claim.
*This response is based on the best information available as of 2/15/24.
Fracture Documentation Inquiry
Question:
Recently a surgeon of ours documented the following for a patient evaluated in our office.
HPI: Right lateral depressed tibial plateau fracture
X- rays: Review of CT and X-Ray shows, “lateral split depressed right tibial plateau fracture with 8mm of lateral joint line depression.”
Diagnosis: Closed fracture of right tibial plateau, initial encounter
Plan: ORIF of tibial shaft fracture noting the joint instability
The coding staff assigned a level 3 encounter to this, and the surgeon is questioning why a displaced fracture requiring surgery would be considered low versus moderate risk for the problem addressed. The surgeon submitted a level four encounter and the staff down coded to a level three. Are you able to comment?
Answer:
Thank you for sending this via our ongoing consulting agreement and agreeing to use this as a coding coach.
Our first answer is to remind the providers, when possible, to address the complexity (risk) of the problem.
Second, the staff should query the provider if they do not understand the type of fracture and associated risk.
Third, the surgeon gave a diagnosis of a closed fracture of the right tibial plateau, initial encounter.
When speaking with the physician, a recommendation to document the diagnosis as “displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture, initial encounter” to better describe the fracture that occurred.
The AMA has defined the Problems Addressed that would be pertinent to this condition as
Acute uncomplicated injury
Acute complicated injury with risk of complications, morbidity, or mortality.
Work with the surgeon to best determine the risk associated with the fracture. This is a great example of where enhanced documentation and speaking with the surgeon has benefits for both.
Additionally, the surgeon stated he reviewed the CT and XR and documented the findings. Remember to remind the surgeon of the difference between reviewing X-Rays and performing an independent interpretation—they are different and impact the level of risk in the MDM table.
*This response is based on the best information available as of 2/1/24.
E&M with Injections: Two Diagnoses
If we have an established patient where the physician evaluates the patient and decides to give an injection. The physician documents two diagnoses. May we report an E&M with the injection because we have two diagnoses?
Question:
If we have an established patient where the physician evaluates the patient and decides to give an injection. The physician documents two diagnoses. May we report an E&M with the injection because we have two diagnoses?
Answer:
An E&M is reportable with the injection when the significant separate service rules are met.
Two answers apply:
- We do not recommend reporting the E&M if the second diagnosis is at same location or joint that is being injected. In this case, a second diagnosis does not meet the “separate service” part of the modifier 25 definition.
- We recommend reporting the E&M-25 if the second diagnosis if:
- The second diagnosis is in a separate anatomic location from the injection site, and
- The second condition is evaluated and managed.
