Wiki Falls risk assessment billing

[ca_cpc]

I work at a primary care office, and we recently hired a PA with a background in ortho. She is going to start seeing patients for Falls Risk Assessments. I'm a little stuck as to the best way to bill these. They are full assessments - physical, vision, and cognitive exams, potential hazards and risk factors, balance and gait assessments, etc - and she'll generally be spending 60+ minutes with the patient. Because they are such extensive visits, we were hoping to bill something other than a general office visit code, but I'm coming up empty-handed. I'm leaning toward billing a 99215, and if she spends enough time, adding a prolonged services code. (We've discussed she needs to focus on documenting her counseling/coordination and medical necessity to substantiate this). I still have to wonder if there's a better option out there - does anyone here have any thoughts?
I'm also wondering what ICD-10 codes I should be using. The bulk of the patient she sees will be Medicare, and the code she wants to use is Z91.81, "At risk for falling," since the idea is to catch people BEFORE they start falling. Obviously, Medicare won't accept this as a primary diagnosis, but I'm at a loss as to what else I can use. Some of the patients may have specific conditions that are the main risk she's assessing, but not all of them.
Thanks!
Christie Anna

 

[thomas7331]

Just my thoughts here as I have not had direct experience with fall prevention services, but I think this is a very risky thing to be billing with a 99215. If the patient is not presenting with a complaint or problem to be treated, and is simply 'at risk', then this is a preventive service, and Medicare covered preventive services are limited to those services which are defined by the statutes. Fall prevention is not one of those services, except as a defined component of the annual wellness visits. A Fall Risk Assessment, in and of itself, is also not a service that is appropriately reported with E&M codes 99201-99215 which are problem-oriented visits, not preventive services. Keep in mind that the Medicare law defines medically necessary E&M services as "those visits necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member".

The E&M code 99215 is the highest level, and it is reserved for the 'sickest' patients and those with the most complex problems. This code is highly scrutinized by Medicare and it is quite likely that a PA in a primary care setting billing this code with high frequency is going to be suspect and will be audited. When Medicare audits these, they look for medical necessity to justify that the patient's condition requires such a high level of care, and to them that usually means some kind of high risk problem or severe or rapid deterioration of a patient's condition. It may be well-intentioned to want to invest this provider's time into fall prevention, and may be a valuable service to the patients, but I think it's very questionable that Medicare would see it this way if you're billing with high-level E&M codes. I would recommend getting an experienced legal/compliance expert's opinion on this before moving forward.

 

[ca_cpc]

Thank you! I hadn't thought of it quite that way, but now that you've pointed it out, it makes me very glad I'm still digging for alternatives. You put it very clearly and it will be very helpful in explaining it to others. (It also makes me feel silly for, if nothing else, not thinking of it as a "preventative" visit, which would have answered the office visit question quite quickly).

I'm still hoping someone else out there might have some guidance for me...It sounds like if we can't find a solid billing tactic to make this reimbursable, management isn't going to allow us to start the program.