Primary Care Coding Alert

Although getting paid for a preventive exam and a problem E/M service on the same visit may seem like an impossible feat, here are six ways to increase your chances for reimbursement. 1. Code for Both With -25. We're talking about a very common occurrence in family practices the patient comes in for a preventive exam, and the FP discovers a problem that must be treated separately. Use the proper-level preventive medicine services code (99381-99397) depending on the patient's age and whether he or she is new or established. In addition, code the appropriate-level E/M office or other outpatient service code (99201-99215) depending on the complexity of the problem, says Lynn Handy, LPN, CPC, director of professional development, consulting and auditing services at Revcare, a healthcare revenue management company in Cypress, Calif., and a Professional Medical Coding Curriculum (PMCC) instructor through AAPC. Attach 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 to show that it is separate from the preventive service.

When you choose the E/M level for the problem visit, try to stay away from higher levels, Handy says. If the patient is sick enough to warrant a high-level E/M, Medicare will wonder why he or she required the preventive service in the first place and may invite closer scrutiny or deny the claim.

2. Match Up ICD-9s. "One of the keys to getting paid for the preventive/problem combo visit is linking the diagnosis codes properly to show the medical necessity of both services," says Marta Kramer, CCS-P, a health information technician at Fairview Lakes Regional Medical Center in Chisago City, Minn. Link a V code (such as V70.0, Routine general medical examination at a health care facility) to the preventive service code, and the diagnosis(es) of the problem(s) encountered to the office visit code.

3. Carve Out the Cost. Medicare does not reimburse for preventive exams, so the patient will be responsible for that portion of the visit. But you do have to bill for both services, Handy emphasizes. Medicare will deny the preventive service and pay the E/M, assuming it is otherwise covered under Medicare. The physician may charge the patient the amount that the physician's current established charge for the preventive medicine service exceeds his or her current established charge for the covered visit.

Medicare reimburses the problem visit based on its usual fee schedule for that service. For example, the physician's usual charge for the preventive service is $100, his usual charge for the problem visit is $50, and the Medicare-allowed amount for the problem visit is $40. If the patient has met her deductible [...]