Wiki Mod -25 preventitive with routine exam

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twinpw

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I have notice recently that some of the docs in the clinics are coding 99386 with a 99214 when a patient comes in for a preventative exam and the doctor works up a medical issue such as gout, hypertension, or hyperlipidemia. The physicians are choosing the 99214 primary and the Preventative exam (the main reason the pt came in for) is listed secondary and adding the modifier -25 to the preventative exam. Shouldn't the preventative exam be listed first with the 25 modifier and the 99214 be listed secondary if documentation support it? Getting confused
 
Yes, -25 should be on the EM service. However, double check to make sure the additional service meets the 99214. If the conditions are chronic stable, no add'l EM is billable. The chronic condition must be uncontrolled/exacerbated and the provider must interviene. Only the History (as it pertains to the problem) and the MDM can be counted towards the additional level. Exam is part of the PE. Same rules apply for a new acute condition.
 
Agree with ormtngirl1963. But, 99386 is for a new patient physical. I have been able to get payment before for a 99201-25 with a 99386, but there has to be good documentation. For the established patients, our internal auditor has advised we would rarely see a 99214 because the exam portion is part of the physical. We usually see a 99213-25.
 
And I will bill a New Pt PE w/an Estab Pt EM - insurance denies 2 new patient codes billed on the same day - guess you cant be a new patient twice! :0)
 
The part that confuses me is the order of placement of the preventative exam and the E&M and where the modifier gets placed. The pt is there for the preventative, the dr. split bills it with documentation. The preventative should be line 1 (since the pt was there for that reason initially) the E&M on line 2. Modifier should be attached to the first line, but I dont think you can put a 25 modifier on a preventive exam, correct? Guess this is where my mind is running around in circles. Billing submitted by dr looks like this (and was denied):
99214
99396 -25
Q0091
I appreciate all the help I can get, because this is keeping my mind racing at night!! Thanks, Pam
 
New patient preventive CPT 99396
Established patient E&M, 99213-25.
You want the new patient CPT code first, and this was indicated as primary reason of visit for preventive care. Then the established patient for the extra work for a separate and significant medical condition. IF the patient was there as a new patient for an acute visit, AND the doctor noted the patient was past due for a preventive care, like a two year old is past due for his two year old preventive care with shots, then you can bill a
New patient 99204-25 for sore throat/ear infection with a
established preventive care CPT for age appropriate exam with vaccinations.
 
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