Evaluation and Management

AMA's Definition of Interval History

CPT Assistant January 2000

An interval history focuses on the period of time since the physician last performed an assessment of the patient. The physician is required to meet the key components listed in the code descriptor, so the documentation required for an interval history will depend upon the level of evaluation and management services provided by the physician. For example, if the physician is providing subsequent hospital care to an inpatient, and the physician reports CPT code 99232 subsequent hospital care, per day, for the E&M, the key componnents listed in the code descriptor of which the physician must perform two of the three) specify that an expanded problem focused interval history must be performed. An expanded problem interval history would address the chief complaint, brief history of present illness, and a problem pertinent system review, focusing on the period of time since the physician last performed an assessment of the patient.

Can I bill allergy immunotherapy and an office visit separately?  

Question: Can I bill allergy immunotherapy and an office visit separately?

Answer: Allergy immunotherapy is the administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale, to an amount that is continued as maintenance therapy. In most cases the patient presents specifically for the immunotherapy injections, and a separate office visit cannot be billed. In some circumstances, however, the immunotherapy and office visit are separate.

The allergen immunotherapy codes (95115-95199) state “Office visit codes can be used in addition to allergen immunotherapy if other identifiable services are provided at that time.” When you bill an office visit with any of these codes, you should attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that it is separate.

If the visit consists only of the allergy shot, a separate visit should not be billed. But if the patient has asthma, for example, and is getting the allergy shots to prevent exacerbation, and you discuss prescription management (e.g., bronchodilator therapy adjustments), these are two separate managements for the same problem. Use 493.xx linked to the allergy shot code (e.g., 95115, Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection), and link the primary diagnosis V58.69 (Long-term [current] use of other medications) to the office visit code with 493.xx as the secondary. Documentation must show that the injection was separately identifiable from the office visit.

When to Code A sick Visit with Preventive Medicine  

Know When You Can Code Preventive and Problem-oriented Services for the Same Visit

Question: An established patient scheduled an annual physical, but when he came in he complained about several chronic problems that had been acting up. The physician performed an examination to check on the chronic conditions, taking thorough documentation, and billed the encounter as an established patient outpatient visit. The physician said the visit had “changed” from a preventive visit (annual physical) to a problem-oriented visit, but what about the “intent” of the visit? Should we charge for the problem-oriented visit because that was the service performed, or should we charge for the preventive visit?

Answer: You can charge for both the preventive visit and the problem-oriented visit. A preventive visit was scheduled, but the physician also evaluated several chronic problems, so bill for both instead of “changing” the visit. Use the appropriate preventive code (99391-99397) and an established patient office visit code (99211-99215), appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code.

The physician must document that the preventive exam was performed and that a separate established patient exam was performed. If the patient only discussed his chronic conditions with the doctor, and the doctor did no evaluation, only the preventive services can be charged. The documentation must clearly show that the physician is proactively evaluating and treating another problem.

The key to ethical reimbursement for this kind of visit is correct diagnosis coding. Link V70.0 (Routine general medical examination at a health care facility) to the preventive codes, and connect the diagnosis codes for the patient’s chronic conditions to the office visit code.

Knowing how much to charge will also help ensure payment. Medicare does not reimburse for preventive services, but states that when billing these and problem-oriented visits on the same day, the practice charges cannot total more than for the preventive exam. You would bill Medicare for the problem-oriented portion of the visit and bill the patient for the difference between your usual charges for the problem-oriented visit and preventive services cost.

For example, if your usual charge for the preventive service is $100 and for the problem-oriented visit it is $60, bill Medicare for the $60 and the patient for $40 as well as any deductible or co-insurance owed for the office visit billed to Medicare. In this case an advance beneficiary notice is not needed because Medicare never covers preventive exams.