Annual exam & problem visit same day

leewagner

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I have one provider(out of 17) that will bill his Medicare patients for a annual exam & a problem visit at the same setting. His reasoning is that if they come with a problem, he will address it. I have no problem with that. The issue I have is his definition of "problem". He considers menopause symptoms, bone denisty results, vaginal symptoms (itching, burning) to be separate identifiable problems. I disagree, I feel all of these are potentially normal items that could be addressed at the time of the annual exam. We go back and forth about this all of the time.
Since he is the only provider billing this way, I am afraid that red flags will soon be jumping up everywhere and we are leaving the door open for audits. I am looking out for the best interest of the practice, maybe I am being over cautious.
Has anyone else experienced similar situation?
 
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prevention focused, not problem focused

Copied from : https://www.healthtradition.com/wp-content/uploads/2012/02/05_HTHP-PreventiveQA.pdf

Q: Why did I receive a bill after my routine preventive exam when it was supposed to be
covered at 100%?

This exam is prevention focused, not problem focused. If you have a new health problem or other diagnoses
that need to be addressed during your preventive office visit, e.g. high blood pressure, diabetes, skin rash, or
headaches, your provider may bill part of the exam at 100 percent for your annual preventive exam and part
of your office visit for treatment of your diagnosis. The portion of your visit related to the treatment of your
diagnosis would apply toward your deductible and coinsurance. If your provider feels that the majority of the
time was spent with medical concerns, the entire visit may be considered a medical treatment visit and would
not be billed as preventive.

Hope this helps,
Laura CPC-A
 
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If you're talking about AWV:

G0439
"Use this code when the provider performs a patient’s subsequent annual wellness visit as a part of the annual wellness program. At this visit, the provider takes the patient’s medical history, assesses risk factors, and provides a personalized prevention plan of service.

This code represents the service wherein a provider receives and follows up with the patient on his subsequent visit as a part of the annual wellness program. The service includes updating patient's medical and family history, current healthcare providers and suppliers involved, physical examinations of height, weight, blood pressure etcetera. The provider updates written screening schedules, risk factors, and diseases that he identified in the initial visit. He also updates health advice and other programs including smoking cessation, physical activity and nutrition, to reduce identified risk factors. The provider works on detailed medical documentation that should be there including patient's medication, treatment history, chronic diseases, urgent health needs and injuries. Policy coverage is provided to the beneficiary for the service once in a year according to the referral of initial preventive physical examination. This code is used for the subsequent visits.

Definitions
Blood pressure: The force that the blood exerts on the walls of all the blood vessels that supply blood to all the organs and parts of the body.
Cognitive: Brain's intellectual activity such as thinking, remembering, reasoning, etc.
Functional ability: Measurement of an individual's ability to execute routine tasks such as standing smoothly and independently.
Risk factor: A physical trait or a habit that makes one more susceptible over others for a particular disease.
Smoking cessation: Quitting the highly addictive habit of smoking tobacco."


None of the "problems" listed would fall anywhere near any of these options. The only things the provider could really do with that information is add to the pt's chart and give general health advice (and referrals, if necessary), with the primary purpose of ensuring the patient's health remains in good standing by encouraging screening exams. He/she could not address the problems directly, discuss them specifically, treat them, examine them, etc. If there's vaginal symptoms, menopause issues, etc, then the provider would either have to encourage/refer the patient to have them examined at another time or by another provider OR examine and address those problems, inevitably creating an office visit charge as well (which would need a modifier).

https://www.cms.gov/Outreach-and-Ed...LN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
 

CodingKing

True Blue
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AWV and physical are two completely different things. A physical is more in depth. If this provider is performing the same physical as they would for a patient with commercial insurance and billing Medicare with a AWV code that alone could cause problems for the practice (obviously Medicare Advantage would be different)
 
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AWV and physical are two completely different things. A physical is more in depth. If this provider is performing the same physical as they would for a patient with commercial insurance and billing Medicare with a AWV code that alone could cause problems for the practice (obviously Medicare Advantage would be different)

Agreed.
 
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