Primary Care Coding Alert

Question: An established patient scheduled an annual physical, but when he came in he complained about several chronic problems that had been acting up. The physician performed an examination to check on the chronic conditions, taking thorough documentation, and billed the encounter as an established patient outpatient visit. The physician said the visit had changed from a preventive visit (annual physical) to a problem-oriented visit, but what about the intent of the visit? I thought that if a patient schedules a physical, I must bill for a physical. Should we charge for the problem-oriented visit because that was the service performed, or should we charge for the preventive visit?

Maine Subscriber  
Answer: You can charge for both the preventive visit and the problem-oriented visit. A preventive visit was scheduled, but the physician also evaluated several chronic problems, so bill for both instead of changing the visit. Use the appropriate preventive code (99391-99397) and an established patient office visit code (99211-99215), appending 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 office visit code.
 
The physician must document that the preventive exam was performed and that a separate established patient exam was performed. If the patient only discussed his chronic conditions with the doctor, and the doctor did no evaluation, only the preventive services can be charged. The documentation must clearly show that the physician is proactively evaluating and treating another problem.
 
The key to ethical reimbursement for this kind of visit is correct diagnosis coding. Link V70.0 (routine general medical examination at a health care facility) to the preventive codes, and connect the diagnosis codes for the patients chronic conditions to the office visit code.
 
Knowing how much to charge will also help ensure payment. Medicare does not reimburse for preventive services, but states that when billing these and problem-oriented visits on the same day, the practice charges cannot total more than for the preventive exam. You would bill Medicare for the problem-oriented portion of the visit and bill the patient for the difference between your usual charges for the problem-oriented visit and preventive services cost.
 
For example, if your usual charge for the preventive service is $100 and for the problem-oriented visit it is $60, bill Medicare for the $60 and the patient for $40 as well as any deductible or co-insurance owed for the office visit billed to Medicare. In this case an advance beneficiary notice is not needed because Medicare never covers preventive exams.