Applied Evidence

10 billing & coding tips to boost your reimbursement

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Omitting the dose indication is another common occurrence. (If you inject a 30-mg dose of ketorolac and submit a J1885 code, which covers a 15-mg dose, for example, it is necessary to indicate that you administered a double dose.) It’s also not unusual for physicians to fail to include all the required codes for patients who receive multiple vaccinations at a single visit.

If a 68-year-old man, an established patient, comes in for an annual flu shot and is given the pneumococcal vaccine during the same visit, the correct codes would be:

  • 90658 (flu vaccine)
  • G0008 (flu vaccine administration)
  • 90732 (pneumococcal vaccine)
  • G0009 (pneumococcal vaccine administration).

Omitting both procedure codes could cost you nearly $20—and could run into thousands of dollars a year if the error is a daily occurrence.

9. Prioritize diagnoses

Many patients present with multiple diagnoses to be addressed during a single routine office visit, each of which may be applicable for billing for services rendered. ICD-9 coding guidelines state that physicians should “list first the ICD-9-CM code for the diagnosis, condition, problem or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided, then list additional codes that describe any coexisting conditions.”10

Selecting the primary diagnosis for billing and coding, then listing the others in order of importance lets third-party payers know how you prioritized patient care—and helps ensure that you are reimbursed accordingly. (Be sure to list active and acute medical conditions discussed during the visit on the encounter form [eg, type 2 diabetes, hypertension] rather than those that are stable and not addressed that day—eg, seasonal allergies or migraine headaches.)

10. Bill extra for emergency services

From time to time, an unexpected office emergency arises that takes you away from the patient you are currently evaluating. In such cases, you can use CPT code 99058 to bill for services “provided on an emergency basis in the office, which disrupts other scheduled office services”—and bill for basic services provided to the patient, as well.4 Documentation, of course, must include the chief complaint, evaluation, diagnosis, and therapeutic plan and fully describe the emergent nature of the service to justify billing for the “emergency encounter.”

Be aware, however, that even when you code and document appropriately, you may not receive full reimbursement. Medicare and Medicaid often bundle emergency services with other services provided on the same day. Other third-party payers respond in different ways: Some pay the full fee; others pay only a small percentage. Depending on the payer’s policy, billing for a level 4 or 5 E/M visit may be preferable.

Dr. Heidelbaugh is a consultant for Takeda Pharmaceuticals North America, Inc. Dr. Riley and Ms. Habetler reported no potential conflict of interest relevant to this article.

Joel J. Heidelbaugh, MD, Ypsilanti Health Center, 200 Arnet, Suite 200 Ypsilanti, MI 48198; [email protected]


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