Physician Practice

Evaluation and Management and Preventive Services-Same Day

Physician Practice Insider, August 11, 2015

 

There are instances when a patient comes in for routine preventive office visits (for example, well-child exam or annual gynecologic exam) and also presents a significant new complaint that requires an additional workup. For example, the patient has difficulty breathing or complains of severe abdominal pain. If this occurs, the visit will become a combination of a preventive and problem-oriented care.
 
Documentation and Coding
 
Current Procedural Terminology (CPT) coding guidelines indicate the evaluation and management (E/M) service should be clearly documented, distinct, and separate from the documentation of the preventive service:
  • Use preventive medicine services codes (99381 – 99397) for the routine exam
  • Use the appropriate office visit code (99201 – 99215) reported with modifier -25 attached, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” for the problem-oriented service
  • Clearly document the appropriate ICD-9 code to the applicable CPT code to help distinguish between preventive and problem-oriented services
Payer and Reimbursement
 
Reviewing and understanding the reporting requirements for each payer is important as each payer will have their own requirements for reporting both preventive and problem-oriented services on the same date.
  • Reporting both preventive and problem-oriented services on the same date can often lead to inconsistent results
  • Some payers will reimburse the full allowable amount for both the problem-oriented E/M code and the preventive medicine services code
  • Some payers will assess a copay for each service
  • Some payers will carve out the reimbursement for the problem-oriented E/M service from the payment for the preventive exam (which results in a total charge that does not exceed that of a comprehensive preventive examination alone)
  • · Some payers will simply deny the claim on the basis that they do not accept coding for both a preventive and problem-oriented service on the same date, regardless of the amount of the charge, because they state you are billing twice for the portions of the preventive and problem-oriented services that overlap
To ensure appropriate reimbursement, review payer guidelines. If there are problems getting paid for both, try reporting either the preventive medicine or the problem-oriented service, depending on which of the two services was the primary focus of the visit and required the most significant amount of physician time and work.
 
An alternative is to have the patient return for another visit to address the management of the problem or the preventive care. Deciding which of these options to choose depends on the clinical circumstances and the provider’s medical judgment. In either case, any diagnostic tests or additional services provided should be reported separately.
 
Payers could decide the following:
  • Reimburse the full allowable amount for both the problem-oriented E/M code and the preventive medicine services code
  • Assess copays for each service
  • Carve out the reimbursement for the problem-oriented E/M service from the payment for the preventive exam
  • Deny the claim for duplicate services for preventive and problem-oriented services overlapping each other
 

This article was excerpted from HCPro’s Physician Practice Billing From A to Z by Charlotte L. Kohler, RN, CPA, CVA, CRCE-I, CPC, ACS, CHBC. Visit HCPro’s Healthcare Marketplace for more information on this book.

 

Most Popular