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Rheumatology Coding Corner Answer: Coding for Incident-to Services

From the College  |  Issue: August 2017  |  August 15, 2017

Take the challenge.
CPT codes: 99214-25, 20610-RT, J1030x1
Diagnoses: M05.79, M25.561

This is an established patient visit with an established diagnosis, along with a new diagnosis, which would have to be billed under the PA’s National Provider Number (NPI) and reimbursed at 85% of the fee schedule. Keep in mind that to qualify as an incident-to visit, there needs to be additional documentation from the physician in his or her own words, especially for a new problem and/or a change to the current plan for an established diagnosis. A split/shared evaluation and management (E/M) visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient in which the physician and a qualified nonphysician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.

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  • A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service.
  • The physician and NPP both must be in the same group practice or employed by the same employer.

The split/shared E/M visit applies only to selected E/M visits and settings (e.g., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and nonfacility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures.

Documentation for split/shared visits should follow the documentation guidelines for any E/M service: Each physician/NPP should personally document in the medical record his/her portion of the E/M split/shared visit and legibly sign and date the record. The documentation must support the combined service level reported on the claim.

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This visit has no documentation from the physician in his own words; therefore, this visit cannot be billed out as incident-to. The visit would have to be billed under the PA’s own NPI number and would receive 85% of the Medicare Part B Physician Fee Schedule.

  • History: Detailed history
    • History of present illness contains five elements: location, timing, severity, context and modifying factors.
    • Review of systems contains eight elements: constitutional, ENT, respiratory, cardiovascular, gastrointestinal, musculoskeletal, integumentary, neurologic and psych.
    • Past family, social history: past medical and social history were taken.
  • Examination: Detailed examination
    • Five systems were examined: constitutional, cardiovascular, abdomen, musculoskeletal and respiratory.
  • Medical decision making: Moderate
    • One stable problem improving and one new problem—extended
    • Radiology was ordered—minimal
    • Uncertain prognosis—moderate

The 20610 is for arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa) without ultrasound guidance.

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Filed under:Billing/CodingFrom the CollegePractice Support Tagged with:BillingCodingincident-to servicespatient carePractice Managementrheumatologistrheumatology

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