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Wiki AWV and E/M same day

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jackiems

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In order to bill for both of these on the same day, is there supposed to be two separate physical exams documented? And does the reason for the E/M need to be an "acute" problem? Some of my docs are trying to bill for both without either of these but they are ordering labs and refilling RX's for chronic problems. What exactly is the criteria.

Thanks
 
I know it is inconvenient for pts but it is best do avoid same day when possible. Having said that this pt should have two appointments on the schedule and should have 2 notes for each visit. This way you do not get dinged on an audit because trying to give a rational of how you determined what documentation was for what can get sticky. So the note for AWV should be coded as should as well as documented and the other note should be for any acute or chronic issues and documented as such. For us if we have a pt that is coming in for an AWV and it turns into an office visit then the Provider addresses the issues at hand and the AWV is rescheduled. This will save you a headache but its not always possible. And don't forget your Modifier(s) hope that helps.
 
One of my docs is wanting to bill for both on every AWV and I just don't agree. And my supervisor, who isn't actually a coder, thinks its ok. So I dont feel comfortable billing for both, plus there is only one note.
 
We do quite a few AWV a year (internal medicine practice with a high volume of 65+ patients). The only time our providers typically do an E/M on the same day as an AWV is for an acute problem; pt complains of being sick or has acute pain. I usually don't have any trouble getting these paid; just be sure the Dx on the claim for the acute problem is on the E/M and also modifier 25. I would certainly be nervous as the biller if the providers were billing both routinely so I understand your concern. Avoid that red flag. :-)
 
I've seen this question come up several times. My take on this issue is that people often forget the patients in this shuffle. Imagine you're on Medicare and you are coming in for what you think is a "free preventive visit". During the course of the visit, your provider is addressing your other concerns, but leaves it at that. A few weeks later you now have a $300 bill in the mail, for what you thought was going to be free.

Since our patients are essentially our customers, how can you improve this customer service? From the provider side, if you already know this might turn into at least partial E/M, inform the patient and let them make the choice whether to reschedule or expect a bill on the E/M portion (which should probably be a low level E/M anyway if billed with an AWV). If I went to the doctor for what I thought was a preventive visit, and I was on Medicare but then suddenly ended up with a $300, I would be upset. I had an AWV provider who would at times bill a 99215 instead of an AWV because of insurance issues or that the AWV was billed too soon. Needless to say, her patients were very upset with her.

Coding-wise if documentation supports both codes, then you can/should definitely bill as appropriate. However, have the provider give the patient a heads up first to avoid any frustrations down the road. It's just good customer service and a win-win.
 
We do this where I work. I am a medical assistant and just got my CPC-A. My provider does an AWV the same day as the 6 month follow up for their chronic conditions like HTN or DM. Then, in 6 months, she does an actual "physical". It is confusing to patients and at first I did not agree with it but it can be billed that way. She has been doing it for a long time.
 
My understanding of the AWV is to also address and bill out all chronic conditions because the industry is moving from fee-for-service to value based care and the emphasis will be on the code selection (DM2 + CKD3). Payers are now wanting to know the severity of illness of the patients and are they getting better/worse.
With that said, if patient does present for an acute condition, the provider will be responsible for ensuring that the documentation in the progress note adheres to the e/m guidelines (history,exam,MDM) and add modifier 25. Hope this helps!
 
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