Practice Profitability

Procedural or E&M Service?

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I recently received an interesting practice profitability question I'd like to share here. It came from a nurse practitioner specializing in urology, especially bladder function, whose visit to a patient in a long-term care facility offered a coding challenge:

I was called in to a long-term care facility to see a patient who had had a suprapubic bladder catheter insertion performed one week earlier by a urologist in an outpatient surgery center. The urologist ordered that I see the patient in six weeks for the first change of the suprapubic tube.

On that day, the primary care NP called me because the suprapubic tube had stopped draining and a bladder scan showed 900 cc of urine in the bladder. She had tried all sorts of repositioning and milking the tube, but with no drainage. I considered this an emergency and went right in to the facility.

When I arrived, the patient was distended and in discomfort, and the tube was not draining. I repositioned the tube, I removed water from the Foley balloon, I advanced the catheter, I made sure it had not been pulled out of place, I milked the tube, getting a couple of clots, and I irrigated the bladder with normal saline. I also spent significant time reviewing the chart and educating the charge nurse on proper technique in changing from drainage bag to leg bag to prevent urinary tract infections. All told, I was there for more than an hour.

My concerns: I consider this high decision-making, because the non-specialist was unable to relieve the problem. I considered the problem to be a danger to the patient, because without intervention, there could have been kidney damage. Changing of a cystostomy tube is a high-value procedure, and I was able to fix the problem without changing the tube. It seems to me that the techniques involved in the managing of the problem are as complex as if the tube were changed. The problem could have been handled by sending the patient to the ER, but we were committed to handling the problem in the long-term care facility, if possible.

What do you think? Instead of a high evaluation and management (E&M) code, should I have used a moderate one with procedure codes? What code would be appropriate for a problem-solving intervention using multiple techniques and technical knowledge?

Procedural or E&M Encounter?

To answer these questions, we need to decide whether this was an E&M encounter (and if so, what kind) or strictly a procedural encounter. I can find only one CPT code listed that really applies to the described procedure: 51701, which is for "bladder irrigation, simple, lavage and/or instillation." There is no code for a complicated bladder irrigation. Changing a cystostomy tube can be either simple (51705) or complicated (51710). However, since the catheter was not changed, neither of these codes can be used, so that leaves us with the bladder irrigation code. Nevertheless, from the effort described by the NP, I don't think that really encompasses everything this patient encounter involved.

The reader stated that the "primary care NP called." This implies a request for consultation. The patient was evaluated and found to be in need of intervention, which involved catheter manipulation and, ultimately, bladder irrigation. Also involved was some patient evaluation.

Although it wasn't specified in the question, it would be appropriate to do additional examination of cardiopulmonary, gastrointestinal and integumentary systems, as well as a psychological exam. The extent to which each is done is up to the provider.

Also mentioned in the question is what sounds like an extensive review of the medical record and teaching of the staff (coordination of care). Depending on what is done and documented, this could be a fairly extensive E&M service (consultation). A look at the consultation criteria shows five possible levels (99241 through 99245) of acuity, each depending on the history, exam and medical decision-making. All three must be included. Don't forget to consider the nature of the presenting problem. If there are a number of comorbidities, the level of acuity increases.

A High-Severity Problem

Based on the information the reader provided to me, I suspect a high-severity problem in this case. As always, the documentation will determine the level that can be billed. If it wasn't documented, it doesn't count.

Considering the probability of a high-severity presenting problem, appropriate care would dictate obtaining a comprehensive history. That means a history of present illness with four or more elements, a review of systems with at least 10 elements and a complete personal, family and social history all need to be documented, reviewed or updated, either on an information sheet or in the encounter note.

A comprehensive physical exam requires either a multisystem exam that includes documentation of two bullets in nine areas, or a complete exam of a single organ system. Since this is a urology problem, a male genitourinary single organ system exam certainly is appropriate.

Finally, the medical decision-making process has to be considered before we can select the correct billing code. This is where understanding the nature of the presenting problem and obtaining a complete medical history pay off. In this case, the patient had urological dysfunction that required placement of a suprapubic tube. It was a problem that was inadequately controlled, worsening (without intervention) and not improving as expected. The patient's other conditions (unknown in our situation) also would be considered if they had been reviewed during the encounter.

The amount and complexity of data to review may be significant depending on the completeness of the medical record. The reader mentioned doing an extensive chart review. The risk of complications and morbidity or mortality is high due to the chronic illness with severe exacerbation requiring intervention. Comorbidities also contribute to the risk and would be determined during the extensive chart review, too. I suspect that at a minimum, the encounter had moderate complexity medical decision-making, but may very well have qualified for a high-complexity medical decision-making level. Without more information, it's hard to say for sure.

Additionally, we could look at time. The reader stated that she was there "for more than an hour." If the actual time was 80 minutes, and that was documented, the selection of the correct CPT code can be based on that element and would be a Level 5 visit or a 99245. It the visit was less than 80 minutes, but met the requirements for a Level 5 visit based on history, exam and medical decision-making, that would be the correct choice, too.

The bladder irrigation code also should be used and a -25 modifier applied to the 99245 code to indicate that not only was a procedure performed, but also a significant and separate E&M service was provided, as well.

If however, the primary event of the encounter was irrigation of the catheter, that would be the only charge that could ethically be used if no other services were provided. The standard of care would dictate that if the provider had no previous relationship with this patient, collection of history either from the patient or the medical record and a physical exam would be expected and appropriate. The medical decision-making process is ongoing and is determined by the overall picture of the patient's health and comorbid conditions.

The answer to the question posed by the reader is that deciding whether to use E&M codes, procedure codes or a combination of both is determined not just by what was done for the patient, but also what was documented in the patient encounter.

Jim Meeks is a family practice PA who works in Orem, Utah, and is the founder of Medical Professional Education and Consultation Services (MPECS). For more information or to find out about the author's four-hour workshops, visit www.mpecs.org or go to www.advanceweb.com/pa and follow the links to MPECS.


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