Diagnosis: 714.0, 535.40
This patient encounter should be coded as 99214-25 and 20610 under the nonphysician provider number, and the expected reimbursement would be 85% of Part B Physician Fee Schedule.
To receive 100% reimbursement of the approved Medicare Part B Fee Schedule, a NPP can only see an established patient with an established diagnosis. This is done by billing under the supervising physician’s provider number.
If an established patient presents with a new problem during the visit, the NPP can either continue the visit and bill under his or her own number to receive 85% reimbursement of the approved Medicare Part B Fee Schedule, or have the physician take over the visit (take the complete history and perform the examination) and bill out the charges under their own NPI number.
It is not acceptable for the NPP to consult with the physician and have the physician give his or her input on the new issue. This is considered a shared visit and shared visits are only allowed for Medicare patients in an inpatient setting.
Modifier -25 is used to indicate that the patient required a significant, separately identifiable E/M service on the same day as the patient received a minor procedure. When a patient is scheduled to have a procedure done, unless there is a significant, separately identifiable issue, an additional E/M visit should not be billed. However, this patient had a separate problem (gastritis) that required evaluation and management services and, therefore, the portion of the encounter related to the diagnosis and treatment of the patient’s gastritis are separately billable with the use of modifier -25.
The E/M services related to the patient’s gastric symptoms include:
- Detailed history: History of present illness was extended, the review of system was extended and the past, family, social history (PFSH) was completed (Once the PFSH is documented and unless there are changes, it is permissible to reference that there was no change from original documentation).
- Detailed exam: There were six organ systems examined.
- Moderate complexity decision making: The number of diagnoses or problems was extended—one stabilized problem was worsening and one new problem with work-up, which was treatment of a side effect (gastritis) requiring a change in medication therapy and additional prescription medication to treat the problem. The amount of data to be reviewed was minimal. The level of risk was moderate for prescription drug management.
