Wiki 99385 & 99203 same day -medical complaints

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jnyjnz

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Patient was scheduled for a new patient prevantative / wellness exam 99385, but it also ended up to be a 99203 new patient E/M as they had medical complaints etc. Provider billed 99385
99203-25


Can this be done? Can it be appealed if denied? Any feedback would be helpful. We bill well established patient visits, with a established E/M code with a 25 modifier, and most insurance companies do pay after we provide medical records with an appeal.


Thanks,

Jenny B
 
When you see a new patient for the preventive visit, any other visit billed (that day, or from that point forward) is an established visit. Patients cannot be a new patient twice.

Bill the 99385 with an established visit code, and with the -25 on the OV.
 
I have to disagree with the previous posts. 1-There is a CPT Assistant date October 2006 that states a new preventive and a new problem oriented visit is appropriate assuming the guidelines for a "new" patient have been met.

Excerpt:

If a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate).

2-CPT clearly states that you CAN report an preventive and a problem oriented visit assuming all the guidelines have been met. These guidelines can be located on the bottom of page 31 of your CPT book.

Now...whether the carrier in question pays for a new preventive and new problem oriented visit is another issue but there are carriers that do pay for both. They may initially deny the problem oriented visit but if you can extract the elements to support that level (99203) and medical necessity has been met, it is worth appealing. Personally, I am skeptical of a 99203 but I suppose it's possible. It may be difficult to determine a proper baseline exam but that is ultimately determined by the physician.
 
Since the CPT Assistant article is four years old, I would venture to say that things may have changed or clarified since then. Your best bet is to check with your CMS contractor.

First of all, a patient can be 'new' only once. So if they are new for the preventive, any subsequent visits are established. Our local carrier, NHIC has this in writing, but your own carriers may vary in their interpretation.

It is possible to extract elements to support an additional E&M visit along with the preventive visit at the same time. A good auditor can ferret out the significant additional work, as long as the provider has documented carefully.

Additionally, CMS recognizes that providers often do address chronic problems (involving significant additional work) at the same time as a preventive visit, and here in NH, NHIC requires us to adjust the amount of the preventive visit by the amount of the office visit. So yes, it is done and can be done.

This may not be the case in all regions of the US, but billing a preventive and an office visit on the same day is definitely an accepted method of documentaton and billing in New England.

Your best bet is to find the regulatory guidance published by your CMS contractor or specific payers. :)
 
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I'm not really worried about Medicare since a traditional PE is statutorily non-covered; other than the "Welcome to MCR PE", thus would become patient responsibility (with notice of course) once carved out. The current CPT book still includes the new problem oriented with the preventive guidelines.... "Modifier 25 should be reported with 99201-99215 to indicate that a significant....."

New PE w/ New problem oriented reporting can and does exist...If it's in black in white, which it is, I'm following those guidelines since I have tangible proof from an authoritative source in case there is a need for an appeal.

As stated earlier, this will certainly boil down to carrier guidelines but the fact is that some carriers still pay for 2 New E/M's based on proper documentation...

UHC=Preventive Medicine services codes 99381-99387, 99391-99397,G0402 include annual physical and well child examinations, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes only--99201-99205 or 99212-99215--when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

G. Reporting a Medically Necessary E/M Service at the Same IPPE Visit (MCR Manual-Chpt 12)

When the physician or qualified NPP provides a medically necessary E/M service in addition to the IPPE, CPT codes 99201 – 99215 may be used depending on the clinical appropriateness of the circumstances. CPT Modifier –25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE code reported (G0344 or G0402, whichever applies based on the date the IPPE is performed). NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary E/M service.
 
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