Practice Management Alert

Education, appeals and documentation can help overturn denials of legitimately billed preventive and problem-oriented E/M services for the same date of service.
 
Last year, Heritage Medical Associates, a 35-physician multispecialty group in Nashville, Tenn., decided that quality care was a priority for its practice. Its goal was to perform preventive services regularly, not just when a patient was sick. Patients received preventive physical exams in which problems were often discovered that required significant and separate E/M work by the physicians. When the practice's billing office submitted claims containing both preventive and problem-oriented E/M charges, insurers denied them even though they were properly coded, says Sandy Adams, assistant business office manager of the practice.
 
An additional problem arose when the practice attempted to recover the patient's share of such claims. Patients who didn't realize they lacked insurance coverage for preventive care complained about the charges. Many of the complaints came from Medicare patients for whom routine preventive care, with some exceptions, is not covered, Adams says. (See box on page 27 for a list of preventive medical care Medicare covers.)
Educate Insurers, Patients and Staff
To eliminate the problem, Adams says her practice is educating insurers, patients and staff on billing preventive care. The effort involves:
  Citing CPT and HCFA guidelines. Adams' customer-service representatives could sometimes convince the payers to review the claim by stating that the services rendered were legitimate billing practices based on CPT and CMS guidelines. Despite this argument, Adam adds, "Most of the time, we had to refile the claim with an appeal letter and medical documentation supporting the charges."
  Remembering that modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) doesn't always ensure reimbursement of both procedures. Adam notes that when the practice used modifier -25 about half the claims were paid only for the preventive care E/M code. "In other cases, some insurers pay the sick portion but don't provide benefits for preventive care," Adam says, "which is denied as 'routine, noncovered' and is billable to the patient because of policy exclusions."
  Appealing EOB denials. The most common reasons insurers list on explanation of benefit (EOB) forms for the denials are "redundant," "not normally performed on the same day or in the same session" or "unbundled," and all are appealed, Adams says.
Things To Note in Appeal Letters
In letters to the insurers defending the claims, Adams notes four items:
 
1. The changes are legitimately billed, referring to HCFA policy on billing a medically necessary visit on the same occasion as a preventive medicine service as detailed in the Medicare Carrier's Manual (MCM).
 
2. The visit and services rendered are properly coded, describing [...]