Monday, March 11, 2013

Good CPT Codes to Know

     If you are a family doctor, or a medical provider who does any degree of primary care--counseling, prevention, healthy lifestyle advice--you need to know and use these codes.  Some are insurance-specific, and others may be used with any insurance carrier.  You may have to fight to get paid, even though the CPT codes are listed on the insurance carriers' fee schedules.
     Chances are, you're performing many of these services already, so you might as well code and bill for them, and get paid for your work.  If not, consider adding some of these services as a way of providing more comprehensive care for patients, and improving revenues for your practice. 

1.  97535:  Teaching a patient about things he or she can do at home to improve a condition, especially dietary interventions for high cholesterol, obesity, or malnutrtion.  Use diagnosis codes like 272.2 (dyslipidemia) or 278.00 (obesity, attach a 59-modifier to the code, and add a 25 modifier to the office visit, as 97535 may be billed in addition to an office visit as long as the diagnosis for 97535 doesn't duplicate a diagnosis for the E/M code.   Aetna, Tricare, some Blue Cross plans. 

2.  G0108:  The Medicare equivalent for 97535, a code for teaching self-care to patients.  Do not use for diabetic self-care unless you have a certified dietician providing this service (this means, don't use 250.00-series diagnosis codes to support this service, or Medicare will reject the claim).  May be used for cholesterol, obesity and malnutrition counseling and home self-care instruction.

3.  99403:  This family planning code may be used only with Medicaid insurance products, and may not be used along with an office visit on the same day.  Since Medicaid has restricted patients to two office visits per month, when they have exceeded their two visits, you may see them a third time for a family planning session, using this code.  Use diagnosis V25.9.

4.  99401:  Another Medicaid-only code, but this one may be used at the same time as an office visit, and both will be covered.  99401 (15 minutes) and 99402 (30 minutes) are codes that represent time a provider spends counseling patients about HIV, including pre-test information, post-test information, discussion of test results, preventing transmission, treatment and prevention of HIV.  Only four 99401 or 99402 codes are covered per person, per year.  Use diagnosis V25.9.

5.  G0396:  Alcohol and/or substance abuse assessment and counseling, up to 30 minutes.  This code is covered by many insurance carriers, but not Medicaid.  It's sister code, G0397 is different only in that it communicates that more than 30 minutes was spent in provider-patient assessment and counseling.  Use a 25-modifier on the office visit, and 59-modifier on the G0396 code.  There is no limit on the frequency of substance abuse counseling, which seems appropriate given the challenging nature of addiction.   Use 303.91 (current alcohol use), 303.93 (history of past use), or any of the many other addiction ICD-9 diagnoses to support this CPT, e.g., THC, cocaine, heroin, or amphetamine use.  I d0 assessments and provide counseling when I have a suspicion that drug or alcohol use is part of the backstory for patients' symptoms, and a screening urine drug test comes up positive.

6.  G0247:  Routine foot care in patients with diabetes or peripheral vascular disease.  There are forms on-line for documenting this exam, which should include pulses, skin and nail exam, sharp and light touch, reflexes and balance.  This CPT code is used to assess the degree of diabetic (or other)  neuropathy and may be done and billed at six-month intervals.  The goal of such exams is to slow down or halt the progression of neuropathy by improving glycemic control, and to assess patients for early diabetic foot ulcers or pre-ulcerative conditions, to prevent terrible consequences, such as far-gone infections and gangrene requiring amputation.  G0246 is used for the first foot exam performed by the provider, and G0247 is used for subsequent exams at 6-month intervals.  Use a diagnosis such as 250.62 (diabetes, uncontrolled, type II, with neuropathy.  Covered by Medicare, but not most other insurance carriers.

7.  11055:  Debridement of callus, for example, on foot, using a scalpel or other Dremel tool with special foot attachments.   Use ICD-9 codes for callus, corn, cellulitis, as appropriate to the patient, and if this is billed with an office visit, attach a 59-modifier to 11055, and a 25-modifier to the E/M code (e.g., 99214-25).  If more than one callus is debrided, most insurance carriers cover up to three, but only if additional modifiers are used:  11055-59 for the first, 11055-59-51 for the second, 11055-59-79 for the third, if it's on the opposite side.

8.  99354 and 99355:  Prolonged visit codes.  If an E/M service (office visit) takes much longer than expected, because the patient is complicated, or because family counseling is required, or there is a need to coordinate care with other specialists or home care providers, the highest E/M code (99205 or 99215) may not do justice to the amount of work you have performed, or the time you have spent making sure the patient receives what he or she needs.  In such cases, code the highest office visit, and then code the prolonged visit as well.  If a provider spends 30 minutes more than the usual time a 99215 would take (45-60 minutes), i.e., 1 hour and 15 minutes, code 99354 in addition to the office visit (99215-25 and 99354-59).  If more than 30 minutes beyond the usual time allotment is dedicated to the office visit, use 99355 as well.  Documentation in the patient's chart must be thorough and indicate why much more time than usual was required for the visit.  An example:  a patient with worsening dementia is diagnosed with Alzheimer's and the family is present.  Medications, placement issues, risk of accidents and falls, caregiver exhaustion, home health nursing and aides, driving, continence, sleep disturbance, behavior challenges and Living Will issues are discussed.  This visit is likely to take much longer than the usual 99215 would cover, and therefore would qualify for 99354 and 99355 codes (the latter is billed for each increment of 30 minutes).

9.  99291:  Critical care.  This code is used instead of (not in addition to) another E/M code.  When a patient is very ill, or unstable, and a provider must care for him or her preparatory to transfer to a hospital or emergency room, this code may be used.  It suggests that multiple interventions are required to protect the patient from imminent danger or deterioration of the presenting condition.  A patient with a severe asthma attack, at risk for status asthmaticus, who needs oxygen, nebulizer treatments, IV placement, antihistamines, a chest x-ray, and may be on standby for epinephrine is an example.  A patient with an acute MI who requires medications, oxygen, IV placement, and moment-by-moment assessment of vitals, with CPR personnel and defibrillation on standby, would qualify for this code.

10.  99441, 99442, 99443:  These are telephone visit codes.  Many insurance companies say they are covered services, but deny the charges when they're submitted.  Medicare and Medicaid do not cover telephone or email visits, but private insurance companies may.  This is a lower-cost alternative to face-to-face visits, and makes sense when patients have problems and questions that don't necessitate a visit, especially if they have been seen in the past few days.  Despite coverage guidelines indicating that email and telephone visits are payable (and make a lot of sense), society as a whole still expects doctors and nurses to talk with patients on the phone for free, and insurance companies capitalize on this expectation by refusing to pay.

11.  99058:  Emergency service.  This code is used in addition to the regular E/M code, and requests coverage for a service provided on an emergency basis.  For example, a patient has chest pain and is thought to be on the brink of a heart attack.  You see the patient, who does not have an appointment, without delay, forcing others to wait.  Use the diagnosis code that represents the reason for the emergency.  Some private insurance carriers cover this, but many have stopped, and Medicare and Medicaid have never covered it.

12.  11720 and 11721:  Toenail debridement.  Toenail clipping and sanding was performed in my clinic using a Dremel drill and special podiatry tip attachments.   It is covered for patients with diabetic neuropathy or peripheral vascular disease of the arteries, and may be coded at no more than every three months.  Documentation in the chart is necessary, and the ICD-9 codes used to support 11720 and 11721 should include both "nail dystrophy"(e.g., 703.8 or 110.1) and either "diabetic neuropathy (355.9) or peripheral vascular disease (443.9).  11720 indicates that one to five nails were debrided, whereas 11721 indicates that six or more nails were treated.  You do not have to be a podiatrist to perform this service or bill these codes.  Use a 25-modifier on the office visit (and don't use nail diagnoses, diabetes, or PVD diagnosiis codes to support the E/M), and use a 59-modifier on the debridement codes.  Don't code the every-six-month foot exam (G0247) on the same day as nail debridement, or they will be bundled.  Nail debridement is covered by every insurance company, if it's billed no more frequently than every three months.

13.  99406 and 99407:  Smoking cessation counseling.  What doctor doesn't counsel patients to quit smoking, and give reasons, warnings, tips, and a review of all the treatments and ancillary techniques available to help them quit?  99406 is the CPT code to use when a provider spends 3 to 10 minutes talking about the benefits of quitting smoking (or staying quit, for those who no longer smoke, but have underlying health problems related to past smoking), and 99407 is the CPT code for spending more than 10 minutes on the subject of smoking, especially when a patient has indicated a desire to quit and wants to put together a plan, with the provider's help.  These codes are covered by Medicare, up to seven sessions per year (more may be covered, under special circumstances).  These codes may be billed at the same time as an office visit, if the ICD-9 diagnoses aren't the same for both.  There is a long list of supporting diagnosis codes, but the  most reliable are 305.1 (tobacco use) and 496 (emphysema, which all long-term--greater than 5 years?--smokers have, to greater or lesser degree).  Use a 25 modifier on the office visit, and a 59 modifier on the smoking counseling code.  Make sure you have a documentation sheet in the chart, indicating what general areas the smoking discussion covered.  Although insurance carriers may not like forms, it's absurd to expect a doctor to hand-write or e-write every word of a smoking cessation discussion in the chart. 

14.  G0180, G0181, and G0179:  Home health care oversight.  Every family doctor has patients who need home nursing care, from time to time.  When the doctor asks a home care agency to step in (e.g., for wound care, diabetes checks, physical therapy, speech therapy, gait training and falls precautions) it is necessary to fill out certification orders--that's when G0180 should be coded, with the same ICD-9 codes the home nursing agency is using.  G0180 may be billed every 60 days.  G0181 is coded every 30 days, as long as more than 30 minutes of time has been required by the physician, in the course of those 30 days, coordinating care (via orders sent by fax or mail, or on the phone) with the home care nurse, aids, therapists, pharmacy, and family.  G0179 is used to "recertify" a patient, for instance after a hospitalization which may have interrupted the home care sequence.  G0182 is the code to use every 30 days when hospice is involved, not a home care agency.  G0180 is used for hospice certification orders at 60-day intervals.

15.  99341, 99342, 99343, 99344, 99345, 99346, 99347, 99348, 99349, 99350:  House call CPT codes.  The first five codes are used for new patients, and the second five are for established patients.  House calls are indicated and covered by Medicare only when the patient is unable to leave the home for anything except going to church and going to a specialist.  99341 and 99346 are nurse home visits (if a nurse in a physician's office makes a visit without the provider) and the other codes equate to office visit codes, with their correlating time-frames.  House calls are a wonderful way to add variety to a practice, fulfill a great need in the community, and return to old-time doctoring, without the horse and buggy. 



  1. Doc,
    Immediately erase all these codes from you memory bank. You need to use your brain for much more important information now. For example, which breed of chickens will produce the most healthy eggs, or which edible fish will flourish in your pond, or what words you can use in Scrabble that will yield the highest points. Now for this counseling session, I am going to bill you insurance company a 97535 with a 272.2 59 modifier, 99214 with a 25 modifier. Have a healthy day.

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