What E&M Code Is Used For An In Patient Consultation Family Practice Medical Coding

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Family Practice Medical Coding

Family practice medical coding includes coding for a variety of procedures, from vaccinations, injections, and immunizations to multiple procedures. General practitioners provide acute, chronic and preventive health care, diagnose and treat diseases, carry out routine examinations, screening and vaccination tests, and even give advice on maintaining a healthy lifestyle. In order to obtain adequate reimbursement, physicians must know how to determine the level of history, examination, and medical decision-making. They also need to know to determine the appropriate level of service provided. Other aspects that require comprehensive knowledge include the various Medicare regulations for consultations, teaching situations, joint visits, and global surgery.

The most frequently used family practice codes

• New patient order visits (99201-99205)

• Established patient order visits – (99211-99215)

• Hospital visits – (99217-99239)

• Other codes for labs and procedures

Family physicians should exercise caution when choosing the level of assessment and management services. Major components to consider in selection include history, examination, and medical decision-making. However, it is important to keep in mind that all three components are required for new patient visits and initial care in a hospital or nursing facility, but only two are required for follow-up care. The nature of the visit and the context in which the E/M service is provided will determine whether two or three key elements are required to indicate the level of service.

• For a new patient, all three key elements are required for the services provided in the clinic, while for an established patient, only 2 key elements are required.

• Three key components are required for a new patient to visit a home/residential facility, while only 2 are required for an established patient.

• 3 key components are required for a comprehensive assessment in a nursing home and 2 key components for follow-up care.

• Hospital-based services require three key components of initial hospital care, initial inpatient consultation and monitoring services; 2 key components are required for follow-up care and follow-up inpatient consultations.

• Emergency Department services require all 3 key elements.

Code consultations and prolonged services correctly

Another important fact about family practice medical coding is that physicians must correctly code consultations and long-term services. Consultations are reimbursed more than routine office visits and initial hospital visits or subsequent hospital care. All consultation requests must be properly documented.

• Codes 99241-99245 for office/outpatient consultation

• Codes 99251 – 99255 for initial inpatient consultations

Prolonged service codes should be reported when you spend more time than usual providing a particular service. These codes are in the range (99354-99359). This time can be personal or the time before or after the personal conversation.

Let’s look at some additional procedures in family medicine clinics:

• Arthrocentesis, large joint or bursa – must be reported with modifier 20610, -RT, -LT or 50 (bilateral).

• Hot/cold package – 97010

• Effective earwax removal – 69210

• Skin biopsy – 11100

• Spirometry – 94010

• Destructive lesion, benign – 17110

• Injection tendon sheath/band/cyst – 20550

• Percutaneous allergy skin tests – 95004

• Influenza virus vaccine, over 3 years of age, intramuscular – 90658

• Electrocardiogram, with interpretation and report – 93000

• Chest X-ray – 71020

GPs have to be very thorough with laboratory and vaccination codes that change from year to year.

Coding of injections

GPs can bill for injections by HCPCS code (if drug/biologic) or CPT code (if vaccine). Medicare reimbursement for the service depends on whether the injection is incidental to the visit or whether it is the main purpose of the visit. However, some private payers will reimburse for a low-level E/M visit, even if the main purpose of the visit is to give an injection.

Learn what modifiers mean

Modifiers should be used with the appropriate CPT codes to further explain the services provided. Family practice modifiers are:

• -25: for a significant, separately identifiable E/M service provided by the same physician on the same day

• -24: notification of surgical intervention provided as a separately identifiable E/M service in the global postoperative period

• -57: indicates that the decision to perform major surgery was made during that visit

How a medical coding company can help

From the details above, it is clear that family practice medical coding involves a lot of detailed study of procedures and codes. For most doctors, it can be a challenge to learn these details and guidelines in the midst of their busy schedules. Your practice can only maximize revenue if you strictly follow payer requirements, evaluate denied claims in a timely manner, and perform the necessary follow-up. A reliable medical coding company with the right staff and infrastructure can be of great help. Most of these companies provide cost-effective services and you can enjoy the services of the best coding professionals who have in-depth knowledge of the coding policies of different payers. They have the latest technology, employ the latest reimbursement strategies and follow advanced billing practices to ensure the best results for their clients.

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