E/M Coding Based on Time

Question:

When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E/M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (e.g., review of tests);
• obtaining and/or reviewing separately obtained history;
• performing a medically appropriate examination and/or evaluation;
• counseling and educating the patient/family/ caregiver;
• ordering medications, tests, or procedures;
• referring and communicating with other health care professionals (when not separately reported);
• documenting clinical information in the electronic or other health record;
• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
• care coordination (when not separately reported).

source: CPT Assistant April 2022

*This response is based on the best information available as of 05/11/23.

Allergy Injections and E/M on the Same Date

Question:

We routinely bill allergy an E/M service when the patient comes in for allergy shots.  Is that acceptable?  Sometimes we bill 99211 if the nurse gives the injection and sometimes if the PA gives the injection 99212.

Answer:

E/M visits should not be reported with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service.  In that situation, report the E/M service with modifier 25 indicating that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided. If the only service provided is the allergy injection do not report an E/M service. Good documentation is key when reporting an E/M and allergy injections on the same date.

*This response is based on the best information available as of 04/27/23.

Allergy Treatment Coding

Question:

What CPT code do I use to report a vial test?

Answer:

There is no CPT code, nor should you charge, for a “vial test.” This is part of the vial provision code/activity (e.g., 95165) and not separately reported.

*This response is based on the best information available as of 04/13/23.

Glossectomy Coding Help

Question:

I have a question about glossectomies. When coding a glossectomy what needs to be documented? My physician just states in the operative report he performed a glossectomy. Is that enough?

Answer:

The answer to your question is no. Glossectomy codes (41120-41150) require removal of a portion or all of the tongue not just the lesion. You must document what portion or how much of the tongue is removed and tongue tissue removal. If only a lesion is removed see CPT code(s) 41112-41114.

*This response is based on the best information available as of 03/30/23.

Adjacent Tissue Transfer

Question:

How should my physician document an adjacent tissue transfer? My physician documents the total in sq cm for the entire repair.

Answer:

The primary and secondary defect dimensions are required. The primary defect is the excision site and the secondary defect results from the flap design to perform the reconstruction. So documentation in the operative report must include:

1. Primary defect-sq cm
2. Secondary defect sq cm
3. Primary defect sq + secondary defect sq cm=CPT code

*This response is based on the best information available as of 03/16/23.

What Does “Separate Procedure” Mean in a CPT Code Description?

Question:

What does “separate procedure” mean when it follows a CPT code description?

Answer:
Per CPT:Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a “separate procedure” is carried out independently or considered to be unrelated or distinct from other procedures, report the code in addition to other procedures/services by appending modifier 59 to the specific “separate procedure” code. This indicates that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).

What does this mean in practice?If a code description includes the term “separate procedure”, if that procedure is in the same anatomic area as a more comprehensive procedure (for example, lyse of adhesions followed by a colectomy) only the more comprehensive procedure, the colectomy, is reported.

*This response is based on the best information available as of 03/02/23.