Practice Management Alert

You can report an E/M and preventive service code--but should you?

Question: How can our practice bill for preventive visits and actually get paid? Can we bill E/M services instead of the preventive codes?

Think you can't receive reimbursement for annual physical exams 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.

Bonus: If you perform the preventive screenings alongside Medicare-covered services such as a medically necessary evaluation and management (E/M) service, you can bill for both--but there's a catch. Keep reading to make sure you know what that catch is.

Don't Switch 99381-99397 for E/M Codes

When a physician performs a preventive visit, you should not report a problem-focused E/M service code instead of the appropriate preventive service code, says Barbara Cotton, president of First Source Medical Resources in Coral Springs, Fla. -You should only code what actually took place,- she says.

Rule of thumb: The reason the patient comes to your office determines how you-ll bill for the service. If the patient comes to your office for an annual exam, that's preventive care. Don't bill an E/M visit just because the physician examined some long-standing problems or refilled some prescriptions. Billing an office visit when the appointment is actually a preventive exam is fraudulent.

Be Up-Front With the Patient

You can bill the patient directly for preventive visits when Medicare or private carriers won't pay, says Barbara J. Cobuzzi, MBA, CPC, OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City.

Good practice: You should let your patients know before their visits if the insurance carrier won't pay for preventive services. Tell the patient exactly how much she-ll have to pay out of pocket. Get her to sign a form stating: -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---or something similar.

Cautiously Apply Modifier 25

If a patient comes in for a preventive screening visit but turns out to have a problem that requires a separate history, physical exam and medical decision-making, you can bill Medicare or other payers for that E/M service. 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 separately identifiable, medically necessary E/M service, Cobuzzi says.

The CPT manual says that you can bill this way, and it's -correct- coding, but often you won't get paid, Cotton says. For example, many private payers will deny you on one of the codes, and then for the unpaid code you will have to make a policy decision about writing it off or going after the patient for payment.

Warning: You should bill a separate E/M service only when the patient had a preventive service and the physician spent a significant amount of time dealing with a problem. Ask yourself if you can find enough carved-out history, exam and medical decision-making to support an E/M service that is not part of the preventive care, Cobuzzi says.

Example: A patient comes in for an immunization and a preventive office visit. Your physician wants you to bill 99214-25 with asthma and eczema diagnoses, 99393 with a V20.2 (Health supervision of infant or child; routine infant or child health check) diagnosis, 90707 with V20.2, and 90471 with V20.2. To be able to report both 99393 and 99214-25, you need to be sure the physician's documentation supports a separate level-four E/M service.

-Remember, the preventive care requires an age-appropriate comprehensive exam, and I assume a pretty full history is taken. You need two of three elements for the E/M service, but I find it hard to carve out elements just for the E/M that are not for the preventive medicine service that can support that high a level usually,- Cobuzzi adds. -You cannot count a service for both the 99214 and the preventive service.- The physician's documentation may support a lower-level E/M service, such as 99212 or 99213, however.