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Don’t Miss Reimbursement Opportunities
Proper coding for emergencies and after hours care can optimize payment for services you provide.
By Douglas
J. Jorgensen, DO, CPC
Dr. Caton is frustrated. He is working harder each day, squeezing in emergencies, seeing patients in the middle of night – Sundays and holidays, too. But still, he is just squeaking by with his payor reimbursement.
If he works harder and sees a patient “after hours” or in the middle of the night on an emergency basis, he should be rewarded for this, right? The answer is “yes he should be”, but if he does not code and bill for it he will not because the payors are not going to point this out.
Several codes exist to help providers be reimbursed for more intense, difficult, or cumbersome services that are “customary” in family or general medical practices.
Remember that laceration that showed up in the middle of your already full morning, or the patient who had abdominal pain at 2:00 am that you had meet you in the emergency department or at your office? Most likely you are billing the E&M codes where appropriate, but are you billing for the additional codes that in some cases can markedly increase your reimbursement?
In this article we will look at some missed opportunities for more optimal reimbursement. Some of these are simply correct coding issues, but the others are simply not being done out of a lack of awareness or the pessimism that pervades payor-payee relations with the overwhelming assumption that they will not pay for these codes.
With this in mind, be certain of one thing. If you do not submit the claim, you will not get reimbursed for it. It is analogous to the old pathology saying: “if you don’t think of it, you’ll never diagnose it.” Simple, yet true.
-22 Modifier
Unusual Procedural Service
This code is
a Level 1, National Modifier found in the CPT Text, Appendix A.1 It
is used when a service or procedure was unusually difficult. Simply
document in the procedure or operation note what was difficult
as well as if it modified your routine technique, etc. If possible,
document why and how it was unusual too.
An example would be excessive bleeding during a biopsy or even with a circumcision. Some bleeding is expected, but if you had to use a suture to control the bleeding that was not a “normal” part of your biopsy and definitely if you had to suture a bleeder with your circumcision, add the –22 modifier.
This modifier enhances payment for the service to reflect a greater level of difficulty encountered in the procedure than you would normally have found. Add the modifier to the CPT code and definitely expect to have to submit your operative note, as most payors will want to verify the “medical necessity” or legitimacy of this code.
However, do not submit your procedure note simultaneously with the bill. If you do, the two items will likely be separated on arrival at the carrier, never to meet again. Thus, wait for the request, but anticipate its arrival by making you documentation clear on why this particular procedure was unusual.
You can bill for this code by putting the –22 modifier on the end of the CPT code (e.g.: 54150-22) or you can put a 09922 as a separate code in addition to the appropriate CPT code.2 One word of caution is not to overuse this code or you will see it routinely denied. Conversely, do not be afraid to use it where appropriate, as you deserve to get paid the extra fee if difficulties are encountered.
Emergency
Code
Code 99058 is
used for “office services provided on an emergency basis.”3 Many
providers never use this code simply because they are too busy
or, unfortunately, because they are unaware it exists. If you “squeeze” in
a COPD exacerbation or even a sore throat patient who was “too
sick to wait,” then these could be deemed emergency visits.
Some doctors prefer to make an office policy where an emergency (i.e.: chest pain, lacerations, dyspnea, etc.) must be just that, an emergent issue. This is not defined in CPT and thus the discretion is your own. Again, be judicious here as these codes are readily paid in addition to your E&M codes and/or procedure codes that you billed for the visit. If you have multiple providers in your office/practice make sure there is uniformity as to how this and similar codes are used. Place this and similar issues in your compliance plan, as it will limit confusion and are quite helpful in the event of an audit.
If you see a hand laceration and your history, physical exam and medical decision making are adequate to make it a 99213, you would bill the laceration repair based on the size of the lesion (adding a –22 modifier if it was particularly difficult closure or repair), then you would bill the E&M level with a –25 modifier. Lastly you would bill the 99058 as this was unscheduled and you should be paid for seeing this patient emergently. See Figure 1.
After Hours Code
As Figure 1 portrays,
if you see someone after your “scheduled” office hours,
you can use the after hours code of 99050.4 This is
billed in addition to the basic service(s) provided. This is not
to be used if you are running late or routinely book patients into “after
hours” slots. Those patients would simply be scheduled patients
whom you are seeing late.
If you closed the office for the day or you were about to close and you get a call and feel the need to see the patient after your routine hours, billing this code is acceptable. Again use this appropriately and it can truly optimize your reimbursement for work you are already doing.
2200-0800
(“10 pm to 8 am”) Code
Doctors are often
seeing patients in the emergency department/hospital setting or
sometimes in the office in the middle of the night. Code 99052
pays for your seeing the patient at these late and/or predawn hours
in addition to the basic E&M or other procedural service.5
If you do not bill for it you will not get paid and like all CPT issues, reimbursement can vary from payor to payor. Some will routinely deny a claim and only after appeal will they pay for it. However, if paid, it sets a precedent for you to get paid the next time you use this code. Furthermore, if you don’t try to get paid for it you never will.
In Figure 1, had the patient been seen at 11 pm, you could have billed this code in lieu of the after hours or 99050 code. There is nothing to say that the two are mutually exclusive; that is, that you could not bill the 99052 and the 99050 together, but we would recommend a more conservative approach and just bill one or the other to avoid potential problems with the payor at hand.
Benign vs.
Malignant Skin Lesions
Like many aspects
of coding, this particular rule makes little to no sense. Most
providers I have audited or met around the country wait for pathology
results to return prior to billing for a biopsy or excision. Getting
pathology on skin biopsies is not only good medicine, but also
excellent coding. Malignancies and precancers are reimbursed at
a higher rate when biopsies and/or excisional procedures are performed
due to the perceived level of difficulty.
However, some doctors are only doing gross visual examinations and making a histopathologic diagnosis and submitting a claim for a squamous cell carcinoma excisional biopsy when in fact it may well have been a seborrheic keratosis. The pathology here is not only critical clinically, but from a coding perspective can have a 3-4-fold increase in reimbursement if it was a malignancy.
Do not bill for unconfirmed, visually diagnosed actinic keratoses or cancers that were destroyed using cryotherapy, cautery, etc. This is fraud. You must have sufficient pathologic evidence to prove that you did in fact have a cancerous or precancerous lesion that you destroyed. Thus, simple visualization is unacceptable.
When you perform your biopsies, have your office manager or front desk staff set those superbills aside and go back to them when you have received a proper pathologic diagnosis. You can then use the proper ICD-9 or diagnosis code and legitimately request your appropriate level of reimbursement.
Summary
A common argument heard from doctors, office managers, and billing staff alike
is “they might not pay for it.” Subsequently they do not submit
the code or claim and no one ever knows.
Be proactive! If the negative statement is “they might not pay for it,” then the flip side is that they might – and sometimes very well. Medicare and Medicaid usually do not pay for the after hours codes. However, if you routinely submit them across the board the private payors may well pay them and the state and federal programs can simply ignore it and not pay you or even send it on to the patients’ secondary insurance.
The point is to give you the opportunity to get paid for the extra service and time you are providing your patients. After all, you deserve it.
Douglas J. Jorgensen, DO, CPC is a family physician with Manchester Osteopathic Healthcare in Manchester, Maine. He is a Certified Professional Coder and founder of Jorgensen Consulting, a national professional services organization offering educational forums and coding consultation. He can be contacted via e-mail at ems@ctel.net.
References:
1. Gordy, TR, Ed.; Current Procedural Terminology 2001; American Medical Association
Press, 2000,Chicago; p. 357.
2. Ibid
3. Gordy, TR, Ed.; Current Procedural Terminology 2001; American Medical Association
Press, 2000,Chicago; p. 352.
4. Ibid
Figure 1: Emergency Visit After Hours 15 yo male c/o laceration. Cut left hand on the thenar aspect 30 minutes ago while cutting up some bait fishing. Washed it with soap and water and his mother called. Advised to meet me here at my office. Stopped bleeding with pressure. Hurts with movement of the hand. |
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| ROS: |
Denies numbness or loss of ROM of the fingers |
| PMH: | Tetanus last summer |
| Social: | Baseball pitcher, but is not a southpaw. |
| FMH: | NC |
| PE: | WDWM in NAD |
| CV: | Radial pulse bounding and strong |
| Neuro: | Without loss of sensation distal to the wound |
| Skin: | 3.2 cm laceration with clean margins, no foreign bodies noted and wound appears clean with oozing . |
| Ext: | Moves all fingers well with equal grip strength and no gross tendon involvement appreciated |
| A/P: | Laceration, 3.2 cm on Left Palm. See procedure note. |
*Please note: Technically, by the 1995 guidelines, I could bill a 99214, but clinically this seems inappropriate. By the 1997 guidelines, a 99213 is appropriate. |
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