New Patient Visit Denied, What Should I Do?

Question:

One of our pain management physicians saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance carrier and was told that the patient was an established patient to the practice and should be reported as an established patient. The patient did see another pain management physician in our group practice who did an injection a year ago, but it was in another city. Is the insurance carrier correct or should I appeal this?

Answer:

Since the pain management physician in the other city is part of your group and is of the same specialty with the same taxonomy code, the patient encounter for the physician in your office should be coded as an established patient visit not a new patient visit.

Per CPT Coding Guidelines: “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of theexactsame specialtyand subspecialtywho belongs to the same group practice, within the past three years.”

Since your claims was denied, it is recommended that you file a corrected claim and bill the encounter as an established patient.

Counting Problems Addressed for Medical Decision Making

Question:

If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?

Answer:

No, sorry, unfortunately it does not work that way. The problems are no additive or cumulative. One stable chronic illness and one acute uncomplicated illness without systemic symptoms is still Low Problems Addressed.

Inpatient E/M Coding

Question:

I did an inpatient consultation and coded 99253 (non-Medicare). I did not need to follow the patient, so I signed off. They asked me to re-consult a week later. What is the code for a re-consult?

Answer:

There are no specific E/M codes for an inpatient re-consultation. You will use the subsequent hospital care code, 9923x, since it is the same admission for the patient.

Question:Follow up question: the patient was discharged then admitted a month later and I was consulted again. Is this a subsequent hospital care code?

Answer:

No, since it is a new admission for the patient, you will use the consultation code again (9925x).

Question:Last question: when I see the patient in my office a month later, is it a new patient?

Answer:

No, it is an established patient (9921x) because you have had a face-to-face visit with the patient in the previous 3 years.

Waiving Medicare Cost-share for Telehealth Visits

Question:

I heard that Medicare patients don’t have to pay their deductible or coinsurance if they have a telemedicine visit. Is this true?

Answer:

Medicare is not waiving deductibles or co-insurance. However, they are allowing providers to do so at their discretion without penalty for telemedicine visits. This means the provider will only be reimbursed what Medicare pays, if the provider chooses to waive the patient portion of the visit. Many payors are waiving cost-sharing for telemedicine visits. See Payor Telehealth Policies for more information.

Steroid Injection

Question:

What CPT code would you use for “anesthetic and steroid injection of the left posterior superior iliac spine?

Answer:

You would report the injection with CPT code 20552.

*This response is based on the best information available as of 08/05/21.

Trigger Finger Injection

Question:

Which CPT code is used 20550 or 20551 for a trigger finger /A1 pulley injection?

Answer:

CPT code 20550 defines an injection to a single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”).CPT code 20551 defines an injection to single tendon at the origin/insertion site.Trigger finger injections are most commonly given to the flexor tendon, supporting CPT code 20550.

*This response is based on the best information available as of 06/10/21.