E/m vs Preventative same day

cstoldt

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My patient scheduled an E/M vist for multiple issues and during the visit the Dr. says you haven't had your annual, so let's do that also. The Dr wants to bill the E/M 99213-99215 as the primary code because that's WHY the patient came in and use the prevenative 99392-99397-25 as the secondary code. I've never seen it billed this way. We have always have billed the annual first with the E/M with modifier 25. What would be the correct way to bill this?
 

btadlock1

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My patient scheduled an E/M vist for multiple issues and during the visit the Dr. says you haven't had your annual, so let's do that also. The Dr wants to bill the E/M 99213-99215 as the primary code because that's WHY the patient came in and use the prevenative 99392-99397-25 as the secondary code. I've never seen it billed this way. We have always have billed the annual first with the E/M with modifier 25. What would be the correct way to bill this?
You can bill both, but if you report it that way, you'll get a denial, because it's contrary to CPT guidelines. Technically, the problem E/M has to go 'above and beyond' the elements of the routine E/M, so the 25 modifier goes on the 99212-99215.

I understand where his reasoning comes from, but it's a bit misguided: only ICD-9 codes have specific reporting requirements, regarding the sequencing of codes. It doesn't really matter what order you bill CPT codes in (some payers have preferences, but there's not any 'official' rules).

What matters (for modifier-purposes), is which service is considered more 'comprehensive' - in this case, it's the well check.

Hope that helps! ;)
 
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