Nursing Visit on the Same Day as Allergy Injections

Question:

Can you bill a nursing visit when a patient comes in for an allergy injection?

Answer:

The routine preinjection and post injection evaluations by the nurse or MA would be included in codes 95115-95117 and would not be eligible to report separately.

When documentation supports that a significant, separately identifiable evaluation and management (E/M) service was rendered, the appropriate E/M code for the service may be reported. All care directly related to the administration of the injection, i.e., the injection cannot be administered without the preinjection and post injection check by the nurse.

However, if the nurse/MA provided any care unrelated to the injection, then code 99211 may be separately reported with modifier 25. However, such instances would be rare, and documentation would need to support both the service and its medical necessity.

*This response is based on the best information available as of 11/03/22.

Implant vs Foreign Body

Question:

What is the difference between an implant and a foreign body?

Answer:

On page 90 of the Current Procedural Terminology (CPT) Professional Edition 2022, the definition was added to the guidelines. “An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant.  An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”

*This response is based on the best information available as of 10/20/22.

Biopsy Coding

Question:

I work at an ENT clinic and my physician is doing biopsies of the soft palate and I’m not sure if this is coded as 11104 or goes under biopsy vestibule of mouth 40808? Thank you so much for your help with this!

Answer:

If the physician is doing a biopsy of the soft palate you should report 42100 (biopsy of palate, uvula.) This CPT code is reported when the physician performs a biopsy on a lesion of the palate or uvula.

*This response is based on the best information available as of 10/10/22.

Pharyngectomy Code

Question:

Do I use CPT code 42950 when a limited pharyngectomy is done??

Answer:

No, you should report CPT code 42890 when a limited pharyngectomy is performed not CPT 42950 (Pharyngoplasty (plastic or reconstructive operation on pharynx).

*This response is based on the best information available as of 09/27/22.

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

*This response is based on the best information available as of 09/08/22.

New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices

What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:

The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

*This response is based on the best information available as of 08/25/22.