ER Counseled on Smoking Q: If a person comes to the ER with back pain & is a smoker & counseled on smoking cessation, is it correct to bill the 99406 in the ER? I have heard both. Wouldn’t you need a 25 modifier on the E/M code? Also, if a pt leaves the ER AMA & does not see the phys, is it okay to code from the nurse’s note? Oh, two-part question.
Coach Schuyler: The important thing with… code is it has to be greater than 3 minutes and up to 10 minutes, so I think it’s important that you really have to document that time. Just like any time-based codes and anesthesia anything else; so that’s important that if you need to provide educational providers and other clinicians that assist in the emergency room you will need to do so.
Now, when it comes to nurses’ notes there are guidelines regarding BMI and if they document Decubitus Ulcer, of any of those ulcer conditions, they can document that. However, the provider has to be the one to diagnose the certain condition. Same thing with BMIs we can’t code strictly just by the BMI the provider has to document obesity, morbidly obese, something like that. We cannot code this by off the nurses’ note. We can use it in assistance as a way to perform CDI or documentation improvement with providers but we cannot do so.
Coach Jennifer: Unless you’re… I’m assuming you’re talking nurse RN, LPN-type of nurse and not a CRNP. Because a nurse practitioner most likely is able to see a patient in the ER and bill for those services but a nurse is not. There is not a 99211 code or anything because remember those also fall under supervision of a physician. So if there is no physician there is no service.
Coach Schuyler: If you have to follow into more of the scope of practice if it is an Advanced Nurse Practitioner, each by each state there are certain regulations that some, like North Dakota they can act alone, they don’t need supervision. However, in other states it’s very different. It’s limited or they can’t do that at all. So, you just have to take that…
Coach Alicia: That’s because North Dakota doesn’t have enough providers.
Coach Jennifer: Yeah. You talk about the rural areas of West Virginia and things like that. Yeah, they allow in rural areas for a nurse to provide those services because they’re understaffed but it would be a state guideline, yeah.
Coach Alicia: But you’re not going to have that in Boston. Houston…
Coach Jennifer: And you got to think, too, what did that nurse actually do for them. They probably couldn’t even do anything. They didn’t give them a prescription, they just took their vitals and said, “OK, the doctor will be with you soon.”
Coach Schuyler: Right. Even with the same as a nurse’s note for the office visit they can’t do anything new. It has to be an established plan.
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