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.)

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.

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 CPT guidelines that are also accepted by CMS.
 
3. The claim is based on standard billing practices and medical necessity. Documentation showing this is enclosed.
 
4. A copy of the appeal letter will be sent to the patient. (For a sample of the letter, see the insert in this issue or view it online at www.codinginstitute.com/docs by entering 29 in the document window.)

Heritage Medical Associates developed a two-sided form to guide the clinical staff in the care of patients, to help promote care quality and thoroughness, and facilitate documentation of services rendered, Adams says. One side of the form aids in documenting the office visit, and the other, the physical examination.
 
"It helps our doctors meet documentation guidelines but also helps them remember all the things to check with the patient," she says. The practice's billing and collections department uses the form as medical documentation to support the charges. The form is submitted with the appeal letter when challenging denials of preventive and problem-oriented E/M charges. (For a copy of the office-visit and the physical-examination forms, see the insert in this issue. The office-visit and physical-examination form are available online at www.codinginstitute.com/docs by entering 30 and 31 in the document window.)

The practice tells patients before their visits that insurance may exclude preventive services and informs them that it appeals insurers' denials.
 
It's important to submit a copy of the appeal letter to the patient, according to Adams, "not only to keep the patient apprised of the situation, but so they can take the document and fight with us to get it paid." In some cases, just showing the insurer that its customer is aware of an appeal can help get the claim paid.
 
To address patients' complaints and questions about being charged for preventive services that their insurers won't cover, the practice has a form on coverage of preventive care. (See the insert in this issue or visit www.codinginstitute.com/docs and enter 32 in the document window.) After checking in for their visit, patients are asked to read the form and sign it.

Nurses and physicians may explain to the patient that the preventive visit could result in out-of-pocket costs if a significant problem requiring immediate problem-oriented E/M services occurs during the visit, Adams says. When patients check out, billing office staff may review with them what parts of the bill an insurer might not cover.
 
The practice is developing a message to add to its automated appointment-reminder system that would tell patients to check their insurance coverage before arriving for their next visit. It is considering having its appointment schedulers remind patients, when they call to make appointments, to check their coverage.
 
The appeals, improved documentation and patient education are working, Adams says. The practice wins many of its appeals, and some insurers are now paying the preventive E/M and the problem-oriented E/M with modifier -25 upon initial submission of the claim, she says.
 
Heritage Medical's problem trying to convince insurers to pay legitimate billing of preventive and problem-oriented E/Ms in the same visit is common for all medical groups, acknowledges Sherry D. Miller, CPC, management service organization compliance officer with Epic Management, L.P., the management arm of the 118-physician Beaver Medical Group in Redlands, Calif.
 
"We've found our best defense with any of our third-party payers is to follow CMS guidelines, and then argue that this is how CMS wants it billed, so you should reimburse us for it," she says. When a preventive and problem-oriented E/M visit is billed for a Medicare patient, CMS guidelines require practices to subtract the problem-oriented visit from the patient's financial liability, she adds.
 
"The charge for a preventive visit is $100. During the visit, another problem is addressed that requires extra work, qualifying it as a problem-oriented E/M. The bill for the problem-oriented portion is $30 which must be subtracted from the patient's financial liability, $100, making the patient responsible for $70," Miller explains.

To receive appropriate reimbursement for correctly coded and billed claims with preventive and problem-oriented E/Ms, Miller and Adams recommend four actions:
 

Make sure the services are coded correctly. The number-one reason for denial of any claim is incorrect coding. Because billing preventive and separately identifiable problem-oriented E/Ms on the date of service can be confusing, double-check the coding, Miller says.
 
If a physician in the Beaver Medical Group wants to bill a higher-level, problem-oriented E/M charge in addition to a preventive-medicine E/M charge, the group submits the claim to peer review. "We do a preposting audit before we even file the claim to ensure it's coded properly," she says. The review prevents filing a claim containing errors and makes sure the doctor, coder and biller understand the guidelines for billing preventive and problem-oriented E/Ms.
 
To avoid mistakes, check that you've followed CMS and CPT guidelines on how to bill such services and used the proper diagnosis codes to support medical necessity, Miller says. Don't forget to use the appropriate modifier as specified in those rules. If your carrier does not recognize some or all modifiers, you will have to appeal, she warns.
 

Verify that physicians document their actions. The preventive-medicine and problem-oriented portions of the visit should be documented separately, Miller says. Heritage Medical developed the office-visit and physical-examination forms to accomplish that. Using a check off type of form to document the physical exam and then dictating notes on the problem-oriented portion will also support the charges, Miller says.
 
Physicians must resist the temptation to help their patients avoid out-of-pocket costs by turning preventive services into problem-oriented ones, Adams and Miller note. "That's billing a noncovered service as a covered service and that's fraud," Miller says.
 

Be persistent with insurers and appeal. "It's not easy, but we must be diligent as providers to appeal these denials," Adams says. Accepting the denials leads insurers to continue to question the legitimacy of the preventive and problem-oriented charges and perpetuates patient complaints, she says. "If you did it, and it's supported in your documentation, bill it and collect it," she adds.
 

Check your payer contracts. Know what preventive services are covered under your contracts. Medicare covers some preventive services, but patients are responsible for charges on the noncovered services. Other insurers also specify what preventive benefits they will reimburse. If a practice knows what preventive services are covered under its payer contracts, it can properly bill the insurer initially, and sometimes avoid the denial and appeal. Additionally, knowing what preventive services are covered can help you educate the patients on the parts of the bill that may be their responsibility.