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Q: This is an E&M related question regarding the "No. of diagnoses and treatment options" in medical decision making. It is a provider based office visit. The patient was seen by Dr. A of the group practice on Jan 1, 2009. There is a follow-up visit on March 13, 2009, by Dr. B of the same practice group. Per the E&M guidelines, because the patient is seen by another physician of the same group practice, he is considered as established patient and the category of E&M chosen is 99211-99215. However, for the MDM, physician B is seeing the patient for the first time, so can we consider them as "New problem to the examiner?" How do we apply the above logic in subsequent visits of inpatients when multiple physicians of the same specialty usually follow the patient on different dates during the entire episode of care? Any supporting Medicare info would be really helpful.
A: It is my understanding that if a provider is seeing a patient for the first time, the problems are new to that provider and can be counted that way when determining the level of medical decision making. I was unable to find any information on the CMS Web site, but I did find this statement on the E/M University Website - http://emuniversity.com/
"E/M University Coding Tip: Problems are defined relative to the examiner, not the patient. Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations."
I hope this helps!
Amy Hodges, CPC, CPC-I
Q: What is the correct CPT code for the insertion of a midline? The tip of the catheter is peripherally inserted into the basilic or cephalic vein, but never goes any further than that vein (from the elbow to the shoulder). The catheter tip terminates at the shoulder. Because it doesn't reach the brachiocephalic, it doesn't appear to qualify as a central venous access catheter. CPT Changes 2004 states a central venous cath or device is one in which the tip of the cath/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium. From this definition, the MLC cannot be a central venous access device. For a MLC, the catheter tip is usually placed to terminate between the antecubital or clavicular areas, not in the superior vena cava, inferior vena cava or right atrium. It is not the same as a peripherally inserted central venous catheter (PICC)?
A: Based on the information that you provided, I would code this case as 36000.
Lisa L. Campbell, PhD, CCS-P, CCS, CPC, CPC-H, CMA
Q: What would be the ICD-9 code for a patient who comes in for a mammogram with no complaints, no history, just breast implants? Also, for the mammogram, would you code this as a screening or a diagnostic mammogram?
A: A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views, per se, do not constitute a diagnostic mammogram, unless there are specific findings that require investigation. (Reference: CMS IOM Pub 100-04 Chapter 18 Section 20). CPT Assistant July 1996 issue stated that "screening mammography is usually limited to two images, such as craniocaudal and mediolateral oblique views. It is performed to detect unsuspected cancer in an early stage in asymptomatic women, and is inherently bilateral. Occasionally, supplementary views may be necessary to adequately visualize the breast tissue. These views are not routine and are included as part of the initial screening service." This reference made it clear that screening mammograms may have more than two view exposures of each breast. I would code ICD-9 code V76.11 or V76.12 for diagnosis code and 77057 (and 77052 if computer-aided detection was also performed) or G0202 for screening mammography procedure code.
June Wang, MS, RHIT, CCS, CCS-P
Q: When a patient has a screening colonoscopy with no history of colon polyps should code V76.51 be used. Or should the reason for having a screening colonoscopy be coded first?
A: The patient is presenting solely for the screening, so I recommend coding V76.51 as primary, followed by the reason as the secondary diagnosis.
Dawson Ballard, Jr., CCS-P, CPC-Coding Educator
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Coding Clinic is published quarterly by the American Hospital Association
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