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Complicated Routine Ante visit

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Korbc

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Uncasville , CT
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Hey there!

I've see verbiage before that additional visits for complicated routine care can be separately billed when unmanaged diabetes, htn, etc are addressed but if it's a routine visit and it involves adjusting any prescriptions, they have these unmanaged conditions, they're going over diabetic logs and spending a lot of extra time and it's not exactly routine care any more am I able to charge a problem e/m for that despite it being a scheduled routine visit and no additional visits were made for the problem. CPT states for these "additional resources may be reported separately" so i would just bill for the separate e/m portion of the visit that was not routine? I've just seen other strict dialogue on this saying if it's at a routine visit i can't bill seperatly unless it's of course a something like a yeast infection or uti and not exactly pregnancy related but just wanted to make sure if it was pregnancy related like gestational diabetes that is unmanaged that i could charge for the extra care being given? I know some of this is payer specific also and I've read some payer policy on this and this scenario isn't mentioned in some of the payer policy

thanks so much!
 
You can bill separately for complications of pregnancy, usually GDM, if certain criteria are met. I know BC/BS, for example, and many of the commercial payers say the same thing, does not want those additional visits billed until the patient has delivered and the "extent" of global package has been evaluated. So what we do is put those type of visits in a hold and then when patient delivers, we take a look at the flowsheet and the documentation for the complicated ones and see if the patient has gone over the typical number of visits the payer has established (many are 16 visits), then level and send out those held visits, with a modifier -25 separating from the global. Say a patient had 20 visits, we could potentially bill out four GDM leveled visits that happened within the last three months (Blue's timely filing usually), in addition to the global. It's not a situation that happens super often but it is helpful. Other payers simply want a modifier -22 on the global code but then you're dealing with sending documentation supporting the extra services. Hope this is helpful and not too confusing:)
 
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