BILLING THE NURSE VISIT
As our coding expert explains, the key to the correct application of the codes for nurse or medical assistant visits, including the 99211 code, lies mainly in knowing what not to bill. There are many questions about when a practice can bill for wound care checks, dressing changes and suture removal. Additional questions arise when practices inherit senior citizens that move into their areas for the winter months. Here, then, are tips, terms and clarifications meant to help avoid the most common measuring mistakes made by dermatologists and their staff. Snowbirds, as they are called, may live in New York part of the year while spending the other part in Arizona. It is not uncommon for a patient to have a surgical service performed immediately before transitioning to an alternate residence. For example, the dermatologist in New York performs the surgical service, while the dermatologist in Arizona does the follow-up visits and removes the sutures. Can the physician in Arizona bill for the services provided, even though he did not do the actual surgery? What about regular surgical follow-up visits? And, under what circumstances are postoperative visits billable? Finally, which CPT and ICD-9-CM codes should be used when it is appropriate to bill for these services? Below we will pose various questions and answer questions commonly asked regarding dressing changes and suture removal services.
Q: Is there a CPT code for dressing change or suture removal that is reimbursed by insurance carriers?
A: There is a CPT code for a postoperative follow-up visit (eg, 99024). However, this is not a reimbursed code by Medicare or any commercial carriers that I know of. Most practices use this as an internal code to track “no charge” visits. What is most important to understand about billing for dressing changes or suture removal is knowing whether or not there is a global follow-up period in place for the surgical service rendered. Many dermatologic services have a 10 or 90-day follow-up period included, while others have no global surgical package (eg, no postoperative days). Procedures such as biopsies (CPT codes 11100, 11101), shave removals (CPT codes 11300 to 11313, intralesional injections (CPT codes 11900, 11901, 96405, 96406), and Mohs (CPT codes 17311 to 17315) have no postoperative period. This means that if the patient requires follow-up visits immediately following the procedure for such services as dressing changes, wound checks, and/or suture removal, the visit should be billed as an E/M visit (if properly documented and service was medically necessary). No modifiers should be needed on the E/M visit, unless some other procedure is billed on the same date of service, or there is a follow-up period in place because another unrelated surgical service was performed.
Q: What if there is no global postoperative period, what level of E/M visit should I bill?
A: That depends entirely on what was done and documented. In most cases, the visit would be a level one new patient visit (99201), level two established patient visit (99212), or nurse visit (99211), since only one body area is examined, and the history and/or medical decision-making are straightforward. However, there may be instances when a visit may turn into an extended visit because the patient needs to be counseled. This happens frequently when a patient returns for follow-up care and the pathology report is discussed. If the discussion turns into a 15- or 25-minute visit, the visit could be billed a 99213 or 99214 based on “time spent.” Obviously, the time must be clearly documented in the chart.
Q: When would a 99211 E/M visit be appropriate?
A: The 99211 E/M visit is a nurse visit and should be used only by a medical assistant or a nurse when performing services such as wound checks, dressing changes or suture removal. CPT code 99211 should never be billed for physician, physician assistant or nurse practitioner services. Additionally, if a medical assistant or a nurse charges 99211, a provider must always be on site to provide direct supervision. CPT code 99211 cannot be charged to any third-party payer if there is no provider on site. The provider does not personally have to see the patient, but must be in the office suite. This is part of the “incident-to” guidelines. The billing of CPT code 99211 in general is very confusing. The “quick-check” checklist (above), can guide you to the correct application of the 99211 code with examples of when not to bill.
Q: What ICD-9-CM code would be appropriate to use when billing postoperative visits?
A: There are a variety of choices. 1. Visits when the pathology results are discussed should be billed using the diagnosis on the path report. 2. Wound checks when there is a complication should be billed using the complication diagnosis code: a. Infection - 998.59 b. Contact dermatitis - 692.9 c. Wound abscess - 998.59 d. Pain (NOS) - 780.96 3. Dressing changes should be billed as follows: a. Dressing change/ removal of non-surgical wound - V58.30 b. Dressing change/ removal surgical wound - V58.31 c. Suture removal - V58.32
Q: Do I need any modifiers appended to the E/M visit?
A: If there is no postoperative period in place and no procedures were performed on the same date of service, no modifiers need to be appended to the E/M visit. If there is a postoperative complication that requires a visit, then modifier 24 must be used. However, the vast majority of the insurance carriers, including Medicare, will not pay for any E/M visits during the postoperative period, even if there is a complication such as an infection. Most carriers will deny the service. If such a denial occurs, an appeal or claim redetermination could be performed although in most instances, the carriers will not reverse their initial denial decision. If there is no postoperative period in effect, but a procedure is also billed on the same date of service, modifier 25 must be attached to the E/M visit.
Q: What if the patient just comes in for suture removal when the surgery was performed by another practice? Can I bill if the follow-up visit is billed during the postoperative period? How do I bill? Do I use modifiers 54 or 55?
A: Absolutely, you should bill for the services you provide. In most instances, you will not even know what CPT code was billed by the surgeon, how many postoperative days the procedure has, or how many postoperative days remain. Since you are in a different practice, you are not subject to the follow-up or global period of the other provider (eg, performing surgeon). Here are some guidelines. 1. If the patient is new to your practice, you may use 99201 to 99203 depending on the level of care rendered, degree of documentation or the amount of time spent counseling. 2. If the patient is an established patient, you may use 99211 to 99214 depending on the level of care rendered, degree of documentation or the amount of time spent. Note: CPT code 99211 is only used if a nurse or medical assistant saw the patient. 3. The visit is rarely just a suture removal encounter. Even if sutures are removed, the wound site is usually evaluated for infection, healing, erythema, edema, etc. The absence or presence of these symptoms should be noted in the chart. Additionally, wound care instructions are usually given and/or reiterated during the encounter. The provision of these instructions should also be noted in the chart. In addition, it is not uncommon for the patient to ask questions about the diagnosis, prognosis or degree of risk. In these situations, the length of time spent should be noted and may even determine the level of care billed. The documentation of the above issues then justifies that evaluation and management services were rendered and are significant and separately identifiable. Important: Do not use any modifiers such as 54 or 55 as they are not appropriate for the scenarios discussed above.
Q: If I have a group practice and one of my colleagues does the follow-up for dressing changes, wound care checks, or suture removal for a surgical service I performed, can the visit be charged since he/she is not the same provider who performed the surgery?
A: No, your colleague cannot bill. He/she is subject to the same global surgical follow-up period because you are all part of the same practice. Billing for these visits would be unbundling, and could be construed as fraud.
Q: Can a 99211 be charged for my nurses' services in conjunction with light therapy?
A: Effective April 1, 2008, Version 14.1 of Medicare’s Correct Coding Initiative (CCI) introduced new bundles that affect the billing of all E/M visits with photolight therapy including E/M visit 99211. 1. The edits do not include new office visits (eg, 99201 to 99205) or outpatient consultations (99241 to 99245). 2. The edits do not include CPT code 96900. 3. The edits only include CPT codes 96910, 96912 and 96913. 4. The bundling of E/M visits with the light therapy codes does not mean that you cannot bill an E/M visit. It means that you must be able to prove that you performed a significant, separately identifiable evaluation and management service. If you performed the E/M, documented it properly, and it was medically necessary, then you can bill the E/M, but you must put modifier 25 on the E/M code. 5. You do not need to have a separate diagnosis code in order to bill both the E/M visit and the light therapy code. 6. Important bundle notice: The nurse visit, CPT code 99211 cannot be billed with the photolight codes even if modifier 25 is attached. The new CCI version has placed the indicator code of “0” on the 99211 code signifying that under no circumstances will they pay for 99211 in conjunction with any light therapy codes — even if modifier 25 is appended. The two codes are no longer billable on the same date of service. Below are the bundles that went into effect April 1, 2008. (Modifier 25 goes on the codes in column II.) Column 1 Column II 96910 99211* 96910 99212 96910 99213 96910 99214 96910 99215 96912 99211* 96912 99212 96912 99213 96912 99214 96912 99215 96913 99211* 96913 99212 96913 99213 96913 99214 96913 99215 *CPT code 99211 has indicator code -0-, meaning that this E/M visit code is no longer payable when billed with CPT codes 96910, 96912 or 96913 for the same date of service.
Q: I have a question about incident-to billing. Can you clear up the incident-to guidelines for me with respect to E/M visit 99211? A: Medical assistants or nurses can provide photolight therapy only under the following circumstances: 1. A physician is physically on-site in the office suite. Note: The name and NPI of the physician who is present and supervising the staff must appear in block 24J of the CMS-1500 form. 2. The patient has been seen by the provider and the provider has ordered the treatment. (The name and NPI of the ordering provider, if different from the supervising provider, must appear in block 17 and 17B of the CMS-1500 form.) 3. The nurse or medical assistant can no longer bill CPT code 99211 on the same date of service when light therapy is performed, based on the bundle changes that became effective April 1, 2008.
Q: What kind of documentation would meet the criteria for a 99211?
A: The “nurse’s note” form I offer my clients is designed to meet many of the aforementioned scenarios. Just log onto the IEPG web site at www.iepg.com/nursenote.pdf You can download the form and use it as you please.
Ms. Ellzey, President/ CEO of the Inga Ellzey Practice Group, Inc., in Casselberry, FL, is an expert on dermatology coding, documentation and reimbursement. She has more than 35 years of experience in the field of dermatology and is also the CEO and founder of two nationwide dermatology billing services.
