Pulmonology Coding Alert

Question: When we see a Medicare patient for a complete physical because of health problems, we are sending it to Medicare with the 99215 code for history and physical. We are entering the diagnosis codes for the illnesses for which the patient needs to have yearly physicals done. We also commonly bill these physicals with an EKG and blood work, which also is done on the visit. Medicare has been denying the 99215 code stating that it is medically not necessary, but they pay for the other services. Is there a way to bill this so the doctor gets reimbursed correctly for the services that have been performed? I know that Medicare allows a physical only once every couple of years, but it is medically necessary for the doctor to do a complete physical annually to make sure he doesnt miss any underlying condition that may be presenting itself.

S.K. Waghray, MD
North Olmsted, Ohio

Answer: You stated that you are performing a complete physical so that you dont miss any underlying conditions. Medicare considers this type of service to be screening, and, unfortunately, it is not a covered service. Medicare will pay only for the level of evaluation and management (E/M) visit necessary to evaluate, test or treat a presenting problem(s).

For example, if you are treating a patient for hypertension, examining the cardiovascular and respiratory systems (two organ systems) would be appropriate. An exam of two organ systems is considered expanded problem focused. So if this hypertensive patient presented for a complete physical (8+ organ systems), Medicare would pay for the two organ systems affected by the presenting problem, and the remaining six organ systems would be considered preventive screening and not covered by Medicare.

If history and medical decision-making meet the documentation criteria, it would be appropriate to bill 99213 (office or other outpatient visit for the evaluation and management of an established patient) for the portion of the visit necessary to treat hypertension, and 99397 (established patient, 65 years and over; periodic preventive medicine reevaluation and management of an individual) for the preventive service rendered. This is called split billing. 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 99213 to denote two separately identifiable E/M services. Be sure to link 401.x (essential hypertension) with the 99213 and V70.0 (routine general medical examination at a health care facility) with 99397.

Medicare also has a charge formula to follow for split billing. Your usual charge for the preventive-medicine visit minus your usual charge for the 99213 visit equals the reduced charge for the preventive service. This patient would be financially responsible for the reduced preventive-medicine fee plus the 20 percent co-pay for the 99213 visit.

Note: The co-pay is usually paid by the secondary insurance if the patient has it.