E/M (or PE?) 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?
 

pamtienter

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Was the appointment made for a physical? If there aren't any problems, it should go back to him for education and a preventive visit billed. They need to keep being told that even though they feel for the patient, it doesn't work that way.
 

apeck

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The E/M code is not a 99215 by any means. You code for the age appropriate E/M code for a physical. If you code this any different and get audited it falls on your shoulders for not coding the visit properly.
 

Lisa Bledsoe

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Bottom line? What was the INTENT of the visit? If it was for a PE, then a PE is what should be coded. I have dealt with this with my providers. It's very difficult to get them to change bad habits, but they need to be educated on the fact that if the patient schedules a PE and they perform a PE but code 99215 that really is fraud. They are not coding for the services rendered...they are coding for payment. Anyone else?
 

Clopton

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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?
Yes, you're right. In most cases if a patient is asymtomatic and is presenting to the clinic for a physical exam or "well check" routine visit, you would bill a preventive medicine new or established age approp. code. that includes a comprehensive history and exam to prevent from capturing such a high level code that isn't really medicallly neccessary. However some organizations may have different set of standards that they go by and it may be more of a workflow issue, I'd suggest discussing this with management.

Rashon Clopton-CPC, CPC-E/M
 
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Madison Area Chapter in Madison WI
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What service was provided and documented? The phrase "physical or annual" exam means different things to different people. Without debating the semantics of the intent, I'd look at what was documented.

Were there "problems"?

Does the documentation support there were no problems and all the preventive services components were met.

If all preventive services components were met and there were also "problems", does the documentation support a significant separately identifiable E/M.

The answers to these questions should lead you to the appropriate service

Just some thoughts.
 

sfinke

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Don't bill until you know!

What is documented is what is billed. Many times a pt will tell a front desk staff & nurse one thing while telling the physician a completely different story. Was the documentation of the visit truly a "sick" visit with a level of 99215? What was the physician's intent? Did he/she knowingly bill a sick visit to circumvent the Medicare no pay policy for preventive visits? Does your physician realize some preventive services are covered? These are serious questions that all coders must educate their physicans about. My advice is do not bill what you do not know. Bill according to documentation. Good Luck!
 

kamkole

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E&M audit-exam components

I have a similar problem and not sure how to handle it. The provider did a breast exam for no apparent reason, but doesn't want to bill it as preventive. She said she met the level 99215 without factoring in the breast exam and feels she shouldn't have to penalize the Medicare patient just because she felt it was appropriate to do. Wouldn't you still have to do this as a carve out, where there wasn't a reason to do the breast exam? Thanks for any help with this!
 

sfinke

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Breast exam / no reason?

Your physician did a breast exam for "no apparent reason?" No reason equals screening so the screening code must be used. Your physician cannot pick and choose what to bill to Medicare. Again, was the visit for an annual exam (no pap performed) but a separate significant visit (99215) done also? Or only the breast exam and a sick visit. If so the G0101 should be charged and an ABN obtained if the exam was done outside of the time constraints of Medicare guidelines. If the full preventive exam was done (99397) and the physician did not want the patient to be responsible so he/she billed the 99215 then the claim was billed fraudulently. This is a tough issue for physicians to deal with and we all realize it, however Medicare is very specific about screening/diagnostic coding. Hope this helps.
 

kamkole

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Yes, the patient only came in for the "sick" visit and a 99215 was billed. The provider said she occasionally does breast exams on her patients and doesn't want to charge them, no pap was done. I didn't think just performing the breast exam would qualify for the G0101 code, don't you have to meet 7 of the 11 elements to bill this? Thanks again for the last reply. This was very helpful!
 
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