Ob-Gyn Coding Alert

Discover the best way to use modifier 25

Think you can't receive reimbursement for annual physical examinations and other preventive screenings? Think again.

Medicare may not cover many preventive exams (CPT codes 99381-99397), but you can still bill the patient directly for them. And if you perform the preventive screenings alongside Medicare-covered services such as an evaluation and management service, you can bill for both. Experts offer the following tips: Tip 1: Remove Reluctance From the Equation Overcome physicians- reluctance to bill the patient for screenings. -Old school- doctors are reluctant to bill the patient, but -I keep telling them they are doing the work and they need to be reimbursed,- says Lisa Center, CPC, coder with Via Christi Health Center in Wichita, Kan. Tip 2: Use the 50 Percent Rule Don't bill a problem-focused E/M when the physician actually performs a preventive visit. Use the -50 percent rule,- says Rhonda Gudell, a coder with Aurora Health Care in Green Bay, Wis. If more than 50 percent of the visit was spent on preventive or related services, then bill a preventive visit. Don't bill an E/M visit just because the physician examined some long-standing problems or refilled some prescriptions.

-Educate the providers that it is fraudulent to bill an office visit if the appointment is a preventive exam,- says Kimberly Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis. -Medicare does do random auditing in order to see if providers are billing what should be a preventive as an office visit.-

Tip 3: Be Forthcoming With Patient Let the patient know up front that Medicare won't pay for all of a preventive visit, and that it's an elective service, says Linda Herrera, MRA analyst with Humana in Kansas City, Mo. Tell her approximately how much her share of the cost will be so there are no surprises.

Sign your name: Ask the patient to sign a form that says, -I am scheduled today to have an annual physical exam. I understand that if my insurance does not pay for this service I am responsible for payment,- says  Christine DuBois, CPC, coding and compliance coordinator for Western Mass Physician Associates in Holyoke, Mass. Tip 4: Remember Modifier 25 When your physician performs a preventive visit on the same day as a problem-focused E/M, use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). If a patient comes in for a preventive screening visit but turns out to have a problem that requires a separate history and/or physical exam and medical decision-making, you can bill Medicare or other payers for that E/M service.

Warning: But you should only bill a separate E/M service [...]