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Billing Preventative visit with/without an additional EM

A

arkolab

Contributor
Messages
22
Location
Lancaster, WI
Thoughts on if you would bill an additional EM or not along with the preventative exam for commercial insurance (BCBS, Quartz, Dean, etc.)? Just looking for some feedback on this and how other facilities are billing out encounters like this. This has been a discussion with our Family Med providers. We are a RHC clinic we bill both professional and facility fee and our providers are paid on RVU assignment. The main question is what classifies as a pre-existing or new problem is addressed during a preventive medicine service (99381–99397) and is significant enough to require extra work to perform the key components of a problem-oriented E/M. There is a disagreement among our coders that everything is stable here and would be considered part of the patient's new "norm" while others say this wouldn't be the standard of care for every person this age and extra work up was done to manage the stable chronic conditions.

ASSESSMENT AND PLAN:
1. Routine physical examination
2. Need for zoster vaccine
- Pap is up to date.
- Colon cancer screening is up to date..
- Routine labs - CMP and lipid panel completed today and pending.
- Routine vaccines - Zoster vaccine completed today.
3. Encounter for screening mammogram for malignant neoplasm of breast
4. Family history of breast cancer
5. Family history of colon cancer
- Mammogram ordered.
- She is also interested in BRCA testing as her paternal aunt and cousins are BRCA positive. Will do MyRisk testing today.
6. Osteopenia of necks of both femurs
7. Screening for osteoporosis
8. Post-menopausal
- DEXA ordered.
- She should continue calcium and vitamin D.
9. Essential hypertension
- Blood pressure well-controlled today at 104/80.
- She should continue lisinopril 2.5 mg p.o. daily.
- CMP and lipid panel completed today and pending.
10. Acquired hypothyroidism
- TSH completed and pending.
- She is currently on levothyroxine 88 mcg p.o. daily.
11. Migraine with aura and without status migrainosus, not intractable
- Migraines are well controlled. She gets them rarely.
- Rizatriptan and ondansetron refilled.
12. Decreased energy
13. Dysthymia
- She takes bupropion XL 300 mg p.o. daily for energy and mental health. She feels she is doing well. Medication refilled.
14. Overweight
- She is on compounded semaglutide. She has successfully lost weight and is happy with her current weight.

SUBJECTIVE:
here today for a physical exam.
She would like to be tested for BRCA gene. Mom with breast cancer (no testing). Paternal aunt with breast cancer and has BRCA gene and her 2 daughters have the gene. Patient's grandmother had breast cancer.
Hypertension - Continues on lisinopril 2.5 mg po daily; no issues.
Hypothyroidism - Continues on levothyroxine 88 mcg po daily; no issues.
Migraines - Has rizatriptan and Zofran as needed. Last migraine was last Friday, able to take ibuprofen and tylenol for pain. She is getting migraines every 3 months or so.
Depression - She is on bupropion XL 300 mg po daily, no concerns at this time.
Still on semaglutide. She is finally happy with her current weight. Feeling good.
Refills: Pended for review if needed.
 
If you crossed out everything stable and related to the preventive, what would you be left with? Would what is left support using a modifier 25 and meet that definition?
This shows everything is well-controlled, refills, basic labs and screening DEXA. Would this patient have come in otherwise? Nothing is wrong.

https://www.aafp.org/fpm/2022/0100/p15 (2022)

Look up policies for the health plan you are sending the claim to. Example: https://providers.anthem.com/docs/gpp/IN_CAID_RP_PreventiveMedsSickVisits.pdf?v=202410011428
Some of the policies have disclaimers like this: "Federally qualified health centers (FQHCs) and rural health centers (RHCs), reimbursed other than through Anthem’s fee schedule or state encounter rates, are not subject to this policy."
You also have to know your contract being a RHC, if there is an all-inclusive per diem or encounter rate, this would make a difference.

https://medlearn.com/icd10monitor/p...lRWbrEWNxTH7g1aVAQKDSvnGNsut0lSTSK9ySQFpH71P2 (2022) Example
"What you have to be careful of is a patient who presents with well-controlled chronic conditions and no complaints, who is asymptomatic and there to “establish care” with your physician. That may be considered a preventive visit by Medicare and commercial plans."

Some health plans have policies that deny this even w/ modifier 25.
 
amyjph said:
If you crossed out everything stable and related to the preventive, what would you be left with? Would what is left support using a modifier 25 and meet that definition?
This shows everything is well-controlled, refills, basic labs and screening DEXA. Would this patient have come in otherwise? Nothing is wrong.

https://www.aafp.org/fpm/2022/0100/p15 (2022)

Look up policies for the health plan you are sending the claim to. Example: https://providers.anthem.com/docs/gpp/IN_CAID_RP_PreventiveMedsSickVisits.pdf?v=202410011428
Some of the policies have disclaimers like this: "Federally qualified health centers (FQHCs) and rural health centers (RHCs), reimbursed other than through Anthem’s fee schedule or state encounter rates, are not subject to this policy."
You also have to know your contract being a RHC, if there is an all-inclusive per diem or encounter rate, this would make a difference.

https://medlearn.com/icd10monitor/p...lRWbrEWNxTH7g1aVAQKDSvnGNsut0lSTSK9ySQFpH71P2 (2022) Example
"What you have to be careful of is a patient who presents with well-controlled chronic conditions and no complaints, who is asymptomatic and there to “establish care” with your physician. That may be considered a preventive visit by Medicare and commercial plans."

Some health plans have policies that deny this even w/ modifier 25.
Click to expand...
Will certainly look into our contracts and see what they say. Providers for the sake of their schedule and the patients' times will often have them come in for their 6-month med check along with the physical. Providers have stated that if they are to not get an extra EM with the physical, they will just make them come back separately for the medication check.
 
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