Question AWV to E & M

Tonyj

True Blue
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Lithonia, GA
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I had a patient scheduled for an AWV which was performed and billed. Medicare denied the charge stating it was too soon as the patient had had an AWV at another facility. The patient states she only scheduled an appointment for a Rx refill but a complete exam was performed.

Question; Can this claim be converted to an E/M visit?
I understand there are other mitigating factors that play a part in billing for an E/M but I just want an opinion from other fellow coders.

The physician's CC is of some concern to me stated as, "79 y/o female presents for medicare preventive care, hypertension, hyperlipidemia and hypothyroidism."

HPI has the status for the chronic conditions listed as well as the medicare preventive service.
Complete ROS; Complete PFSH; Complete Exam; MDM High

Can this claim be converted from a preventive to an E & M?
 

jimbo1231

Expert
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Hi Tony, Based on the documentation I think switching to an E&M would be questionable. The provider documents that the patient visit was for preventive care and the issues documented are chronic issues which are usually part of a preventive care visit. If the provider had documented for example that there was a significant BP increase and medication changes were required, an E&M might be medically necessary. But I don't see that. Also the documentation doesn't appear to meet the requirment of an AWV which is very specific and not the same as a Preventive Visit.

Jim S.
 
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Amityville, NY
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Hi Tony,

I would suggest that patient's eligibility for AWV is checked on Connex website. Some programs that provide eligibility, will list the date patient is eligible for service as well. For example, my providers use EPIC. Within the response for eligibility it gives you dates patient are eligible for the preventive services. Hope this helps.

Andrel J
 

Pathos

True Blue
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Beaverton OR
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Hello,

I agree with the above posters. The purpose of the visit is what should be coded, regardless of what insurance says. Even with time documentation, an E/M sounds questionable at best. The way to prevent this mishap again is to have someone check for Medicare eligibility before hand. Perhaps have the scheduler assigned to check on the dates?

I remember I used to work for a provider who only did AWV visits. This provider would always include time documentation, and when the claim was denied due to AWV was too soon, this provider would change the visit to an 99215, based on time. I strongly disagreed with this practice for several reasons. First, is the reason I provided above. Second, imagine the patient coming in for what they think is a "free" preventive visit, only to receive a $300+ bill because the scheduling messed up. This provider received many complaints (I know I would be upset if I was their patient) due to this practice, and I believe the provider stopped billing based on time again. I would talk to the office/coding manager and see if this is a process that could get implemented. Sound be a win-win for all parties as the practice gets paid, providers get paid, and your patients don't have to pay an E/M bill for what they thought would be "free".

Hope this helps!
 
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