E/M audit question

meganpoelzer

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Does anyone know what do in a situation where a physician is billing a 99215 but cc clearly states "pt here for physical exam". It is obvious that the doctor is trying to get around the fact that Medicare does not cover preventive exams but it's my understanding that if a patient is getting a PE done, we need to bill a PE.

I have an auditing form that has hx, exam, and decison making but how can I use that if patient cc is PE? Does the doctor get zero as far as E/M and should it be changed to age-appropriate PE?
 

LLovett

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You are right, you have to bill based on what was done, not what will get paid.

I would tell the provider they need to change it to the preventive service if that is what was documented. There are times when you could have a problem office visit and a preventive visit at the same time but you can not subsitute a problem visit code for a preventive because the insurance won't cover preventive.

I know the doctor is trying to help the patient out, but billing medicare for a non-covered service coded incorrectly as a covered service to get paid is fraud.

Laura, CPC
 
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I agree...

A PE is a PE. And when the chief complaint is "here for a physical", it's been my experience that insurers expect the physician to bill a physical. On internal audit, that's what I would say, too. I wish I had some great resource to back this up, but its just my judgment call.

I had a physician who routinely did this--PE=99215. As an auditor, it's hard to tell the difference if the documentation requirements are otherwise met and the patient gets a complete physical, but has many stable chronic problems. The notes start to look like E/M at some point when really its just a comprehensive physical of a person with chronic conditions. Unfortunately, these are the gray areas we have to navigate.
 

RebeccaWoodward*

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Do you think it's a matter of wording? The reason I ask...we had a similar situation. Many of our elderly population would call in to schedule an appointment for a "check up", when in reality, they were there to get their medications refilled and have lab work drawn for their chronic conditions (HTN,DB,Anemia, etc). The labs were drawn to ensure their levels were stable. When I spoke with my provider, he really had no idea how his recording of the CC, "check up", impacted his record. Suggestions were given for re-wording the CC so that the medical necessity could be easily identified. The intent was not to be misleading for the visit but to accuratley identify why the patient was really there. Since the patient did not have any complaints, the physician used the 3 chronic conditions for his HPI documentation. The status of each one was thoroughly documented and his HPI was met.

Just food for thought...:)
 
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It's all in the wording.

I'd agree, "check up" is kind of gray wording, but when the provider clearly says "routine physical" like mine did--there is no question. At least not to the payer that audited my doc.:)
 

RebeccaWoodward*

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I agree Belinda....routine physical is exactly that.

We have had patients come in for a trigger point and then decide they wanted a complete PE while there. (Medicare patient). I have always recommended the "carve out" method...Your thoughts?

• First, select the most appropriate code for the preventative (routine/physical visit) visit (codes 99381-99387 or 99391-99397).

• Next, select the most appropriate Evaluation and Management (E/M) code for the medically necessary portion of the visit.

• Subtract the appropriate Medicare Allowed Amount for the medically necessary E/M visit from your charge for the preventive exam.

• The remaining balance is what you will charge for this portion of the exam. This portion will be a "non-covered" service.
 
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100%

Yes. I agree with that completely. I think that's the "spirit" of the carve out--giving the patient a financial break for things during a physical that are medically necessary for the treatment of something else like trigger point injections.

I have been having this discussion with one of our lead docs because as a coder, it's hard to decide what was done for the physical and what was done for the medically necessary portion unless the provider separates their documentation. It's nice when two notes exist from an auditor perspective because there are no arguable points as to what goes to the E/M.

I agree Belinda....routine physical is exactly that.

We have had patients come in for a trigger point and then decide they wanted a complete PE while there. (Medicare patient). I have always recommended the "carve out" method...Your thoughts?

• First, select the most appropriate code for the preventative (routine/physical visit) visit (codes 99381-99387 or 99391-99397).

• Next, select the most appropriate Evaluation and Management (E/M) code for the medically necessary portion of the visit.

• Subtract the appropriate Medicare Allowed Amount for the medically necessary E/M visit from your charge for the preventive exam.

• The remaining balance is what you will charge for this portion of the exam. This portion will be a "non-covered" service.
 

meganpoelzer

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Thanks for all of the feedback! I understand and agree with what everybody is saying. I think it would be appropriate to bill preventive with "carve-out" (we routinely do that for all of our patients that have new or pre-existing problems that require additional work) but how do I do an official audit of this?

I am doing quarterly audits for all providers and I'm not exactly sure how to put this in writing for the doctor to understand. I don't think it would work to use E/M audit form. Do you think it would be a good idea to say, "CC is PE, therefore a PE must be billed..." and just write a report on this and use E/M audit form for the carve-out?

By the way...this doctor knows what he is doing and essentially I want to audit him on this to show him it's not acceptable to us and won't be acceptable to Medicare.
 
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