Split Billing Is Risky Business

Danger is imminent if the chief complaint and unique documentation don’t support separately billed services.

An example of so-called “split billing” is when the provider performs a physical exam and also discusses the patient’s chronic pre-existing conditions, linking the chronic diagnosis codes to the office visit and the reason for the visit (V70.0 Routine general medical examination at a health care facility) to the preventive service.

This sort of billing is, in my opinion, dangerous and ill-advised.

Preventive Visits Include a Review of Chronic Problems

If the patient makes an appointment for a routine physical and is asymptomatic at the time of the encounter, discussion of chronic problems and medication refills are an expected part of the exam—not something extra that may be billed. If the patient is asymptomatic, there is no chief complaint to support anything beyond the well visit.

Another type of split billing is the well/sick patient. For example, a patient requests a routine annual exam, but upon presentation expresses a symptomatic problem. In other words, there is a separate chief complaint to support a sick visit, in addition to the well visit.

The patient is requesting two visits in one day (one preventive, another for a problem) and should be billed accordingly. But the office visit for the problem should not exceed a level II encounter because:

  1. You cannot count the elements that are a part of the preventive visit toward the elements of the office visit; and
  2. The problem must be minor. If the patient is so ill that a level III or higher visit is required to address the problem, the patient is also too ill to allow the provider to capture a good “baseline” reading, and is too ill to undergo the annual exam (or other preventive service).

When reporting a preventive visit and a problem-focused visit on the same day, you must append 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 problem-focused visit code. The Centers for Medicare & Medicaid Services (CMS) specifically allows a separate evaluation and management (E/M) service with the annual wellness visit (AWV), but requires:

“… a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology codes 99201-99215) billed at the same visit as the Annual Wellness Visit, (AWV) [must be] billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.” (https://questions.cms.gov/)

Note the explicit requirement of documented medical necessity in the guidelines. When billing a split encounter, I advise (and some payers require) the provider to write two separate encounter notes (one for each visit). If you’re charging for two encounters, that’s what the chart needs to reflect.

ICD-10 Changes on the Horizon

Let’s fast-forward to Oct. 1, 2014, ICD-10-CM implementation. Although the procedure codes are not changing (yet, that we know of), new diagnosis codes may change the rules of split billing.

For example, the ICD-10-CM code categories for general exam are:

Z00        Encounter for general examination without complaint, suspected, or reported diagnosis

Excludes1: Encounter for examination for administrative purposes (Z02.)

Excludes2: Encounter for pre-procedural examinations (Z01.81), special screening examinations (Z11-Z13)

Z01        Encounter for other special examination without complaint, suspected, or reported diagnosis

Includes: Routine exam of specific system

Note: Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed.

Excludes1: Encounter for examination for administrative purposes (Z02)

The applicable subcategories then become:

Z00.0     Encounter for general adult medical examination

Applicable to: Encounter for adult periodic examination (annual) (physical) and associated laboratory and radiologic examinations.

Excludes1: Encounter for sign or symptom—code to sign or symptom general health check-up of infant or child (Z00.12)

Z00.1     Encounter for newborn, infant and child health examination

Z01.0     Encounter for examination of eyes and vision

Excludes1: Examination for driving license (Z02.4)

Z01.1     Encounter for examination of ears and hearing

Z01.2     Encounter for dental examination and cleaning

Z01.3     Encounter for examination of blood pressure

Z01.4     Encounter for gynecological examination

Excludes2: Pregnancy examination or test (Z32.0), routine examination for contraceptive maintenance (Z30.4)

In every case, the description is clear that these codes are not reported with other diagnostic codes. As such, there will be no rationale for charging a preventive visit and an office visit when an asymptomatic patient presents for an annual exam—even if the provider discusses current treatment and medication refills for chronic conditions.

The Excludes1 notes make it clear that the patient cannot be examined for a symptomatic issue and also charged for an annual exam. Excludes1 is a pure exclusion note, indicating, “not to be coded here.” As such, a patient can no longer receive two visits on one day.

Note, however, that each subcategory contains the choice of “with abnormal findings” or “without abnormal findings.” If the patient presents with no problems or complaints, and the provider discovers a problem during the preventive exam, the documentation must be clear on this point. You are then instructed to code the findings secondary.

How Would You Bill for the Encounter?

Remember: It’s the patient who decides how much healthcare he or she wants. If the primary reason for the encounter is preventive, and the patient didn’t request the additional “visit,” it doesn’t make sense to split bill. Nor would you want to explain to the patient why there is now a co-pay for what was originally intended to be a free preventive encounter. The December 2010 CPT® Assistant further qualifies:

“The regulations specify that plans cannot impose cost-sharing requirements, such as co-pays, coinsurance, or deductibles with respect to specified preventive services in which preventive services are billed separately. When these services are part of an office visit, the office visit may not have cost sharing if the primary reason for the visit is to receive preventive services. However, cost sharing is permitted for an office visit when the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not delivery of the covered preventive services.”

These examples illustrate common situations involving preventive services and how they are handled:

  1. A 45-year-old male individual receives a cholesterol screening test—a recommended preventive service—during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.
  2. An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. The plan or issuer may impose cost-sharing requirements for the office visit.
  3. An individual receives a recommended preventive service that is not billed as a separate charge (i.e., it is part of the office visit and the delivery of said service is the primary purpose of the office visit). The plan or issuer may not impose cost-sharing requirements for the office visit.

Scenarios 1 and 2 show how an office visit with an unplanned preventive service is subject to patient cost sharing, and modifier 33 Preventive services is not used. Scenario 3, however, describes a planned preventive service that is billed as an office visit, and should not have patient cost sharing. Appending modifier 33 will allow the payer to recognize this.

Billing a preventive visit with an office visit using modifier 25 will cause the patient to have an unforeseen co-pay. If you follow the guidelines to the letter and bill as one encounter that is primarily preventive using modifier 33, however, the patient won’t incur a co-pay for the visit (which is what was planned).

Sometimes, it’s up to coders to educate payers about how to use certain codes and modifiers. Often, it takes carefully worded appeals before a payer understands that using modifier 33 with a problem-based E/M when abnormalities are found during a preventive visit makes sense. It satisfies the patient and keeps his or her benefits and expectations intact; and it allows providers to code the higher level of service they performed.



Debra Mitchell, MSPH, CPC-H, is a coding and compliance consultant and auditor, as well as a professional instructor in coding, billing, and medical terminology. She has developed several courses for adult education programs in medical coding and billing and has contributed to the development of a coding certification program. Mitchell was recently named to the Biltmore’s Who’s Who in America’s Professional Women. She is a member of the Columbia, Mo., local chapter.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “Split Billing Is Risky Business”

  1. Chris Galeziewski; CPC, CEMC says:

    Not a good article, draws some erroneous conclusions, examples are wrong – the supposed codes (PE) used would not be billed in the first place; since a provider would not be co-listing DX’s for each code the prospect for accurate slit billing will be better defined and supported.; in my opinion. Not a good article despite her Biltmore.

  2. Cheryl Eccleston, CPB says:

    I agree with Chris. The concept used to support this article is poorly developed. Guidelines for use of Modifier 25’s, what this author is referring to as “split billing” are clearly outlined by the AMA. A patient presenting for a physical with no complaints asking for script fills has never qualified for Mod-25 use. A patient presenting with new symptoms, concerns, complaints, or requesting significant counseling outside of preventive guidelines would qualify, in ICD-9 or 10. Many diagnostic issues can be addressed safely while obtaining baselines, but could still easily be documented at a level 3 or 4 E&M. That is completely dependent on your physician & their decision making process. As long as our health system is Fee For Service, billing for services rendered, following the actual AMA guidelines, will always be appropriate.

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