Wiki E/Ms with MDCR wellness

[dtricia]

Our auditor allows providers to bill an E/M with Wellness visits when patient presents without complaints, but get labs done. This has the 'potential', but provider is not giving a status of the condition of the patient with regard to the Problem the lab is being ordered for. To me this is important, otherwise it is just a lab order. We have no HPI, no presenting problem other than the Wellness . The labs are linked to a problem dx. There is detailed exam. sometimes refill of a medication, but not always.
I know you only need 2/3 to determine complexity but with no CC for this office visit is modifier 25 supported?. I do not have a Presenting Problem.
I have been shot down on this and just wanted other opinions.

 

[Pathos]

Correct Coding can allow an AWV with an E/M if medical necessity dictates the need for it. Since medical necessity is such a vague term, many coders (including AAPC) have tried to quantify what that means through a tool called the Marshfield Clinic tool (the one with the points). Having worked both sides of the equation (payer and provider), my suggestion is to stick with the coding guidelines as much as you can, and then look at the payer policies. Even though a visit could qualify for a Consultation visit (9924x), some insurances won't accept this code no matter how hard you appeal (like Medicare). Similarly, some payers will accept AWV+E/M, and some will always deny no matter what you say or do.

As to what to do with your example provided, there is some discussion on importance of the Chief Complaint (CC). CMS E/M guidelines requires a CC, and if audited the documentation should support a good CC.
However, what you are describing appears to be a routine preventive visit. The whole purpose of an AWV is to go over every single chronic condition, check on medication, do the HRA and other AWV required elements. Some payers are also recommending doing a comprehensive exam, and reimbursing providers by doing so as well (a decent amount of RVU added).

Unless there is an actual problem or problems that needs to be addressed (new problem/significant change in problem, etc.), then you would be hard pressed to defend such documentation against an audit.

Sources:

CMS E/M guidelines