Avoiding the Shoals of Contracts and Codes
The nice thing about complete ignorance is that you treasure every emerging glimmer of competence. After I successfully coded my first sore throats and sinus infections, I felt irrationally triumphant. I started to get excited about coding. I thumbed through the massive coding encyclopedia and discovered codes for obscure problems and even more obscure circumstances. Codes for eyeworms and familial Mediterranean fever. Codes for falling off a cliff or out of an airplane.
One day I recorded a 917.6 (foreign body, superficial, foot, noninfected) and the associated procedure code, CPT 28190 (removal, foreign body, superficial, foot, noninfected.) Linking 917.6 to 28190 meant that I'd removed a splinter. I added an E849.0 to clarify that the splinter was acquired at home, not at a place of work or business. I couldn't decide who would be more stunned: My mother, if she knew how many 917.6/28190/E849.0s she'd performed when I was a child. Or myself, if I'd known when I entered medical school that this was how I'd be applying my hard-earned education.
Luckily, my friends from residency who were also entering practice were going through the same torture. One sent me an e-mail with the subject line "Coding Seminar." The message went like this:
"911.0: Abrasion, superficial, trunk [includes penis]. E918.0: Caught between two objects. Really, they should put warning labels on zippers."
Despite my flights of coding fancy, I was still having trouble with the basics. Reluctantly, I dialed the Coding and Compliance number. "I have a couple of questions..."
"We can come down."
Linda and Karen arrived with remarkable alacrity, smiling cheerily. They were very pleasant and very bright; they just didn't speak the same language I did.
They sat down across the desk from me. I'd already figured out that the process would go better if I had a clear question, so I started out briskly. "I'm trying to
One day I recorded a 917.6 (foreign body, superficial, foot, noninfected) and the associated procedure code, CPT 28190 (removal, foreign body, superficial, foot, noninfected.) Linking 917.6 to 28190 meant that I'd removed a splinter.
figure out this whole thing with the preventative exams," I said. "I understand that there's a distinction in billing between a preventative visit and a treatment visit. But I'm confused about what to do when there are elements of both."
"You shouldn't do both in the same visit."
"I understand that ideally they'll be separate. But I can't tell someone, 'I know you've taken the day off from work to come here and see your doctor, but three of the items on your list are preventative and two are nonpreventative, so you'll just have to come back another day.'"
"I know the doctors don't like it," Karen said severely. "But that's the way the system is."
I tried again. "The doctors don't like it because it doesn't fit the way people think. Our patients come in with questions, and we try to address them. These distinctions seem artificial. I'm trying to understand them so I can work with them."
Linda sighed and shifted uncomfortably in her chair. "Well, there is one thing you can do," she said. "If you really have to do both in one visit, you can do a dot-two-five."
"You can do it as a preventative and then do a dot-two-five modifier on an E and M." I remembered that "E and M" stood for "evaluation and management," so I didn't have to embarrass myself by asking what itmeant. But "dot-two-five" was another matter.
"What's that?"As I asked the question, I noticed that Karen was looking at Linda in alarm, as if she had divulged a state secret.
"It's an extra code you can put behind the preventative code," Linda said, "and then you can bill an E and M for the same visit. Like, if at the end of a physical somebody suddenly had chest pain and then you evaluated them for that."
"So I can do both!"
"Yes," said Linda.
"But . . ." cautioned Karen.
"But most insurances don't take dot-two-five modifiers."
"So what happens if I try to code one?"
"Well, it's legal—you won't have committed insurance fraud. But they'll just pay for one of the two; usually they pick the cheaper one."
"So I can bill for both if I do both—I just won't get paid."
There was a long pause while I rubbedmy throbbing temples. "Okay," I finally said. "Let me think about that for a bit." What I was thinking was something like, Boy, I could save myself a lot of headaches and just open a coffee shop instead. There are no dot-two-five modifiers for coffee.
But what I actually said was, "My other question is simpler. I'mtrying to figure out how to bill a physical. I had someone