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Family Practice Medical Coding
Medical coding for Family Practice includes coding for a variety of procedures from immunizations, injections, and immunizations to multiple procedures. Family doctors provide a variety of services in acute, chronic and preventive medical care, diagnosing and treating diseases, conducting routine checkups, screening and vaccination tests and even giving advice on maintaining a healthy lifestyle. To get the right compensation, doctors must know how to determine the level of history, examination and medical decision making. They also need to know to determine the right level of service provided. Other aspects that require a comprehensive knowledge include the various Medicare regulations regarding consultations, teaching situations, shared visits and global operations.
Most Frequently Used Family Codes of Practice
• New patient office visits (99201-99205)
• Established patient office visits – (99211- 99215)
• Hospital visits – (99217- 99239)
• Other codes for labs, procedures
Family physicians should be careful when choosing a level of evaluation and management services. The main components to consider while choosing include history, examination and making a medical decision. However, it is important to remember that all these three components are required in the case of new patient visits and initial care provided in a hospital or care facility, but only two are required for to follow up care. The nature of a visit and the setting in which the E/M service is provided will decide whether two or three key components are needed to define the level of service.
• For services provided by the office for a new patient, all three essential components are required, while for an established patient only 2 essential components are required.
• Three key components are required for a new patient visit home/home facility, while only 2 of them are required for an established patient.
• Three key components are required for a comprehensive assessment of a nursing home, and 2 key components for subsequent care provided.
• For services provided in a hospital, three essential components are required for initial hospital care, initial inpatient consultation and observation services; 2 key components are required for subsequent care and follow-up inpatient consultations.
• For the services provided by the Emergency department all 3 essential components are required.
Code of Practice for Consultations and Long-Term Services
Another important fact about family practice medical coding is that practitioners must code correctly for consultations and long-term services. Consultations receive higher fees compared to routine office visits and initial hospital visits or follow-up care provided by hospitals. Each request for consultation must be properly documented.
• Codes 99241 – 99245 for office/outpatient consultations
• Codes 99251 – 99255 for initial inpatient consultations
Extended service codes should be reported if you spend more time than usual providing a particular service. These codes are in the range (99354-99359). This time can be face-to-face time or the time before or after face-to-face time.
Let’s take a look at some of the procedures that family practice offices do:
• Arthrocentesis, major joint or bursa – 20610, to be reported with modifiers -RT, -LT or 50 (bilateral)
• hot/cold pack – 97010
• Affected removal of earwax – 69210
• Skin biopsy – 11100
• Spirometry – 94010
• Destruction wound, bad – 17110
• Injection Tendon sheath/ligament/cyst – 20550
• Percutaneous allergy skin tests – 95004
• Influenza virus vaccine, age 3 and above, intramuscular – 90658
• Electrocardiogram, with interpretation and report – 93000
• Chest X-ray – 71020
Family practitioners must be very thorough with laboratory and vaccination codes that change every year.
Coding for Injections
Family doctors can bill for injections using an HCPCS code (if it’s a drug/biological) or a CPT code (if it’s a vaccine). Medicare payment for the service will depend on whether the injection is incidental to the visit or whether it is the primary purpose of the visit. However, some private payers pay for a low-level E/M visit even if the primary purpose of the visit is an injection.
Understand What Modifiers Stand For
Modifiers are to be used with the appropriate CPT codes to further explain the services provided. Family Practice modifiers include:
• -25: for a significant, separately identifiable E/M service provided by the same physician on the same day
• -24: to report a surgical procedure provided as a separately identifiable E/M service during a global post-surgical period
• -57: indicates that the decision to perform major surgery was reached during the visit
How A Medical Coding Company Can Help
From the aforementioned details it is clear that the practice of family medical coding involves a lot of detailed study about methods and codes. Most doctors may find it difficult to master these details and guidelines amidst their busy schedule. Your practice can only increase revenue by improving compliance with payer requirements, evaluating denied claims in a timely manner, and performing 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 benefit from the services of some of the best coding professionals who have in-depth knowledge about the coding guidelines of various payers. They have the latest technology, use the latest payment strategies, and follow advanced billing practices to ensure the best results for their clients.
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