Billing Questions

afryberger

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Lebanon, PA
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Hello,I have a couple billing questions. I did take the billing course but it didn't answer specific questions I had so I'm assuming this is more of a work experience deal. Any help and information would be very much appreciated.
1) Medicare and Preventive. So our provider did an annual well visit, not a welcome to medicare or there AWV, on a medicare patient. I know medicare doesn't accept the preventive codes. I'm being told to change it to a regular EM code, since we don't have an ABN on file. I'm having trouble finding the information that does states to do this. If we don't have an ABN on file, shouldn't it be adjusted off as non covered? If we had one, then we can bill the patient, correct?
Follow up, what if they have a secondary, if Medicare wont pay, can we send it to the secondary?
2) Medicare and the G codes, with a secondary insurance. After Medicare pays for the G but leaves a balance, what if the secondary insurance doesn't accept the G code? Does it just get adjusted off? Do we change it for the secondary insurance to a regular CPT code? Wont that cause an over payment? Do we put a note in box 19 of what the G codes is with the CPT code and not change is on the actual form?

Sorry i have so many questions. I tried googling and CMS but its hard to find answer to specific questions. If it helps, this is for New Jersey.
 

SharonCollachi

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I'll take on question 1: If your provider did something that is not covered by Medicare, and you didn't inform the patient in advance and get an ABN, it's a write-off. You can't change the E&M code to fit what will pay, you can't bill the patient. The schedulers should not be booking procedures (the wellness visit) without checking to see if it can be done, or someone should be checking well in advance of the visit. Whatever you do, don't have patients sign blank ABN's or "routine" ABNs. I still run across practices (when taking my Mom to the doctor) that still try to do this.

My only advice on question 2 is that whatever Medicare says is the patient's responsibility is, in fact, the patient's responsibility. You don't write it off because the secondary doesn't recognize the code. I do not have good guidance on how to handle changing the code or not, because I haven't had this issue in years.
 

Orthocoderpgu

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It's been several years, but Medicare introduced an "Annual Wellness Visit" that is meant to be performed after the "Welcome to Medicare" visit on a yearly basis. However, in order to bill the code several very specific items must be documented. The physicians I was coding for at the time were audited and none of their "Annual Wellness Visits" had all required items documented. I forget the code for this but it's there. Just a place for you to check out.
 

csperoni

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I'll throw my 2 cents in here too.
1) Preventive visits are non-covered by Medicare. Non-covered do not require an ABN. Modifier -GY would be appropriate here.
That being said, from a "customer service" perspective, I WOULD have patients sign the ABN and collect payment at the time of the visit. The patient may have felt the visit was really for medication renewal for the hypertension and high cholesterol, but the provider documented and coded as a preventive. From my experience, most patients on Medicare have at least 1 minor chronic issue. They are not 28 year old athletes. If the services were already provided without informing patient she would owe, I would use it as a learning experience. Contact the patient and let them know Medicare does not cover preventive, and that any preventive in the future would be patient responsibility. Any preventive for this or any other Medicare patient in the future should get an ABN, or if you feel it's not necessary since it's not required, at least informing the patient verbally. But I would do the ABN and collect at time of visit. That way it is 100% clear. Also note: some secondaries which are not Medicare supplements might cover the preventive denied by Medicare.
2) Many patient's secondary is a Medicare supplement (like AARP) which will recognize and process/pay anything Medicare approves, including G codes. For those, it is not even a concern. Secondaries that are NOT Medicare supplements will also sometimes recognize G codes. For those that do not, I would write an appeal letter. I do not change my coding for secondary insurance, since the claim will no longer match the EOMB.
 

afryberger

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Lebanon, PA
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I don't know where to go from here. I just don't what she is doing is correct.
This is what the email said: "as long as the AWV documentation guidelines are met then they should be coded, however if the AWV are not supported but an E&M is supported then those should be billed. The service that should be billed is based on the documentation in the medical record" She had it changed to 99213.
Notes:
CHIEF COMPLAINT: yearly physical HPI: comes in today for annual physical. Follows with Podiarty, dentist, eye doctor , ENT and Neurology. Has not seen Hematology or Pulmonology since admission for PE and pneumonia. No recent issues with cough/SOB. At usual activity level .
REVIEW OF SYSTEM: CONSTITUTIONAL: Patient denies fevers, chills, sweats. No fatigue. weight changes -stable. EYES: Patient denies any visual symptoms. EARS, NOSE, And THROAT: + difficulties with hearing-right hearing aide. No symptoms of rhinitis Or sore throat. CARDIOVASCULAR: Patient denies chest pains, palpitations RESPIRATORY: No dyspnea On exertion, no wheezing Or cough. Uses CPAP. NO respiratory issues-continues with nebulizer treatments bid. GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, no change in bowel pattern. No blood noted.No heartburn. GU: No urinary hesitancy Or dribbling. No nocturia Or urinary frequency. MUSCULOSKELETAL: No myalgias Or arthralgias. NEUROLOGIC: No chronic headaches. No dizziness Patient denies numbness, tingling Or weakness. PSYCHIATRIC: Patient denies problems with mood disturbance. No problems with anxiety/depression. No outburst. Talks to "unseen" person at various times of the day-able to be redirected. ENDOCRINE: No excessive urination Or excessive thirst. DERMATOLOGIC: Patient denies any rashes Or skin changes. ALLERGIES: Doxycycline:Unspecified HISTORY: Past Medical History: Down's Syndrome HOH- right PE- 8/2019- No DVT Social History: Never Smoker
EXAM: General: Well appearing, well nourished, in no distress. Oriented x 2, normal mood And affect . Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising Or prominent lesions HEENT: Head: Normocephalic Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL Ears: EACs -dry cerumin. TMs Nose: No external lesions, mucosa non-inflamed, septum And turbinates normal Mouth: Mucous membranes moist, no mucosal lesions. Teeth/ Gums: No obvious caries Or periodontal disease. Pharynx: Mucosa non - inflamed, no tonsillar hypertrophy Or exudate Neck: Supple, without lesions Or adenopathy, thyroid non-enlarged And non-tender Heart: No cardiomegaly Or thrills; regular rate And rhythm, no murmur , No bruit. Lungs: Clear to auscultation . No wheeze/rhonchi Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, Or hernia Back: Spine normal without deformity Or tenderness Extremities: No edema. peripheral pulses intact. No abnormal weakness. Musculoskeletal: Normal gait And station. Normal ROM of extremities. Neurologic: CN 2 - 12 normal- limited assessement Psychiatric: Oriented X 2 normal mood and affect.
DIAGNOSTIC ASSESSMENT: Z00.01: ENCOUNTER FOR GENERAL ADULT MEDICAL EXAM W ABNORMAL FINDINGS...Z00.01 Q90.9: DOWN SYNDROME, UNSPECIFIED...Q90.9 J45.20: MILD INTERMITTENT ASTHMA, UNCOMPLIC...J45.20 G47.33: OBSTRUCTIVE SLEEP APNEA (ADULT) (PE...G47.33 E03.9: HYPOTHYROIDISM, UNSPECIFIED...E03.9...E03.9 M81.0: AGE-RELATED OSTEOPOROSIS W/O CURREN...M81.0 I26.99: OTHER PULMONARY EMBOLISM WITHOUT AC...I26.99 TREATMENT PLAN: Will stop albuterol treatments and continue with Budesinide Needs repeat chest xray s/p pneumonia eailer this month Needs f/u with Hematology and Pulmonology for new Dx PE Complete lab work MEDICATION PRESCRIBED/RECONCILED: Patient's medication has been reconciled. quetiapine ER 50 mg tablet,extended release 24 hr:1 tablet by mouth daily; Dispense:30; (6/25/2019) Depakote 500 mg tablet,delayed release:1 tablet by mouth twice a day; Dispense:60; (2/21/2019) Nexium 40 mg capsule,delayed release:1 capsule by mouth daily; Dispense:30; (2/21/2019) ferrous sulfate 325 mg (65 mg iron) tablet:1 tablet by mouth daily; Dispense:30; (2/21/2019) metronidazole 0.75 % topical cream:1 application apply on the skin daily; Dispense:1; (2/21/2019) Oyster Shell Calcium 500 mg calcium (1,250 mg) tablet:1 tablet by mouth daily; Dispense:30; (2/21/2019) Prolia 60 mg/mL subcutaneous syringe:1 mL inject below the skin ; Dispense:1; (2/21/2019) levothyroxine 112 mcg tablet:1 tablet by mouth in the morning; Dispense:90; (6/25/2019) montelukast 10 mg tablet:1 tablet by mouth daily; Dispense:30; (2/22/2019) Reguloid oral powder:1 gm by mouth daily; Dispense:369; (3/4/2019) budesonide 0.5 mg/2 mL suspension for nebulization:1 mL inhale twice a day; Dispense:60; (5/29/2019) quetiapine 300 mg tablet:1 tablet by mouth Select Frequency; Dispense:; (3/29/2019) levothyroxine 112 mcg tablet:1 tablet by mouth in the morning; Dispense:90; (3/29/2019) budesonide 0.5 mg/2 mL suspension for nebulization:1 mL inhale twice a day; Dispense:60; (5/21/2019) ferrous sulfate 325 mg (65 mg iron) tablet:1 tablet by mouth daily; Dispense:30; (7/11/2019) Calcium 500 + D 500 mg(1,250 mg)-400 unit chewable tablet:1 tablet by mouth daily; Dispense:30; (7/15/2019) Eliquis 5 mg tablet:1 tablet by mouth twice a day; Dispense:60; (9/5/2019) sertraline 50 mg tablet:1 tablet by mouth daily; Dispense:30; (9/5/2019) ciclopirox 8 % topical solution:1 mL apply on the skin nightly; Dispense:1; (9/5/2019) LAB RESULT AND TESTS ORDERED: The following lab tests are ordered: X-RAY - A-I-0068:CHEST PA & LATERAL REGULAR - 004259:TSH 005009:CBC With Differential/Platelet 010322:prostate-Specific Ag, Serum 096206:Varicella-Zoster V Ab, IgG 303756:Lipid Panel 322000:Comp. Metabolic Panel (14)REFERRAL: BILLING INFORMATION: 99396 x 1.00 unit(s) - Preventive visit, established, age 40-64 SIGNED OFF SIGNATURE:
 

csperoni

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Selden
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It's been almost 20 years since I coded for primary care, but I don't think I would have any issue with using E/M for this. I don't see this being preventive, which to me is more about counseling/risk reduction/screening (and I don't see that here). There are multiple problems being addressed and treated. In fact, 99213 seems undercoded. Just because the clinician put 99396 at the end does not necessarily make it a preventive visit.
 

afryberger

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Lebanon, PA
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I didn't go off that for this being a preventative visit. Annual exams fall under preventative CPT codes. Documentation: CHIEF COMPLAINT: yearly physical HPI: comes in today for annual physical. That is where my confusion lies. I know also he did a full exam; the Medicare AWV doesn't include a full physical exam. So the G codes wouldn't be applicable. I see this : Will stop albuterol treatments and continue with Budesinide Needs repeat chest xray s/p pneumonia eailer this month Needs f/u with Hematology and Pulmonology for new Dx PE Complete lab work MEDICATION PRESCRIBED/RECONCILED: Patient's medication has been reconciled and i think that would be more of a EM visit because of a chronic condition. I just want to make sure I am not doing anything that is not compliant. Thank you everyone for helping me out.
 
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