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CPT codes: 99214-25, 20610-RT, J1030x1
Diagnoses: M05.79, M25.561
Explore this issueAugust 2017
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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.
- 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.
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.