Denial for 99214

Question:

I work with Dermatologists. I have taken a couple of your online webinars. I have a question regarding a denial of office visit 99214, I hope you can answer. The denial indicates that medical records do not support the level of service. In that type of situation, can we rebill the claim as a corrected claim to a 99213?

Answer:

I would not just change the coding to 99213 without reviewing the documentation first. In 2021 the guidelines for office or other outpatient E/M services changed in that either time or medical decision making determines the level. Of course a clinically relevant history and examination should be documented. I would review the note for the date of service denied and code the encounter based on the documentation and not just assume 99213 is the correct code to report. If you need E/M training for Dermatology KZA can help provide education to you and your dermatology practice on coding and documenting E/M services.

*This response is based on the best information available as of 11/17/22.

E/M Visit During the Global Period

Question:

Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure?

Answer:

Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated to the original procedure and reflect a clear plan of treatment for the new/unrelated issue. You will then append modifier 24 (unrelated E/M in a global period) to the E/M code.

Cleft Lip Repair

Question:

What CPT code do I use to report the repair of the cleft lip with a cross lip pedicle flap and sectioning and inserting the pedicle? I was told to report CPT 40527

Answer:

The correct code to report is 40761. CPT 40527 does not include sectioning and inserting the pedicle.

Billing an E/M Service on the Same Day as an Oral Food Challenge

Question:

My physician always bills an E/M service with CPT codes 95076/95079.  Is this allowed?

Answer:

It’s rare to bill an E/M code with an oral challenge unless the provider needs to treat for a reaction (intervention therapy – a separate service) or the provider saw the patient for an unrelated office visit the same day as testing.

The office visit cannot be part of the testing and needs to significantly separately identifiable. You cannot double-count the testing time for both the oral challenge and the E/M code! If you do code an E/M visit with an oral challenge, add modifier 25 to the E/M code (99202 – 99215).

*This response is based on the best information available as of 11/17/22.

E&M Coding Based on Time

Question:

Our physicians default to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally), perform injections, and reduce fractures in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent.

With that said, the activities you identify, because they are billable services represented by other CPT codes (aka are separately reported), do not contribute to the total time spent; this time must be deducted from the total time, assuming the E&M service is reportable.

Counting Laminectomy Levels

Question:

I am confused and hoping you can clarify a coding question I have. I thought I understood how to report laminectomy levels, however, after recently reading an article in the AHA Coding Clinic HCPCS Volume 22, Number 2 Second Quarter 2022 publication, I doubt myself. The surgeon performs and documents a L2, L3, L4 laminectomy with decompression (lateral recess). I have always coded this as 63047, and one unit of 63048. The coding publication I was reading states to report 63047 and 2 units of 63048. Have I been coding incorrectly by only reporting one unit of 63048?

Answer:

Thank you for contacting KZA for clarification. We understand your concern when reading various publications and seeing articles that are not consistent with what you thought you knew.

Without seeing an actual operative note, we agree with how you have coded this type of case in the past. Let’s take a look why.

CPT code 63047 is defined as “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)),single vertebral segment; lumbar”

A “vertebral segment” means per motion segment. The decompression of the existing nerve root is performed in the interspace between the two lamina.

L2, L3, L4 when looked at closely defines two motion segments:

L2-3 =63047

L3-4= 63048 x 1 unit.

To report a third unit of 63048, the surgeon would either have had to go “up a level” to L1-L2, or “down a level” to L4-5.

We appreciate your verifying your coding practices.

*This response is based on the best information available as of 11/17/22.