Internal Medicine Coding Alert

Published on Sat May 28, 2005 PDF

Correctly coding same-day sick and preventive exams is easier than you think

Although Medicare covers new initial preventive exams, it doesn't pay for traditional preventive checkups, even when your internist addresses separate health problems during the same visit. This means you need to become a master carve-out coder.

How it works: "Medicare has rules that state if you are seeing a patient for a preventive physical exam but the patient also has a significant, separately identifiable problem (this even includes chronic problems that the physician follows on a regular basis), then you must bill Medicare for the portion of the visit that would normally be covered," says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multispecialty healthcare network in South Portland, Maine.

For example: A patient who has had Medicare for several years schedules a routine preventive exam. When the patient arrives, she also complains of dizziness (780.4) and abdominal pain (789.0x). Therefore, your internist and/or nurse performs the preventive and performs a separate examination of the dizziness and cramps.

Assuming the documentation is correct, you would report the example as follows:

99397 - Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, established patient; 65 years and over

99213-25 - Office or other outpatient visit for the evaluation and management of an established patient; significant, separately identifiable evaluation and service by the same physician on the same day of the procedure or other service.

You should append modifier -25 to 99213 to show that your internist performed a separately identifiable E/M visit in addition to the preventive exam, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Landsdale, Pa.

Even though Medicare won't pay for 99397, you should still report and bill for both codes. The key to getting paid for both is to bill the patient the difference between the charge for the preventive and the E/M service, Falbo says.

Example:   99397 = $60
                     99213 = $35

Patient pays:          $25

Important: Medicare patients often have secondary private insurance that may pay for the preventive visits, Larabee says. "However, we have to bill for the services as Medicare requests. If there is a carve-out involved, then that is the way we bill."