Wiki Patient is requesting code change from office visit to preventive


True Blue
Everett, Washington
Best answers
Commerical Insurance Patient is asking if her level four office visit can be changed and billed out as a preventive visit. She was seen by this doctor (endocrinologist) 8 months with her dx's 244.9, 272.4 and 733.00.

I've been researching this issue and cannot as yet come up with a definitive answer. Can specialists bill preventive visits? What steps should I be taking to get an answer on this? Would a peek at the chart notes offer some clue? Just need some guidance... Looking back on past history of the way this particular doctor bills, he never bills for preventive visits, so am just wondering how we might address this going forward??

Thoughts advice, or words of wisdom please!
What does the documentation state? It would be unusual for an specialist to bill for a preventative visit when she all ready has the disease the physician is managing. If the intent of the visit is for follow up (Cheif Complaint) for a current disease i.e. hypothyroidism, it cannot be billed as a preventative visit.

We inform our patients that the documentation must support the code billed. For us to change that to avoid their responsibility for a copay is not appropriate and violates rules and laws up and down the spectrum.

There are limitations to what specialists are able to utilize and not recieve severe scrutiny by the carrier.
Your patient is asking you to change the code because of the new guidelines of the Affordable Care Act, that allow 100% coverage of preventive visits.

Be careful. To re-code a claim only to satisfy payer or patient coverage rules is fraudulent. Why was the patient seen? If your provider is treating a condition, or investigating symptoms, then this is not preventive care.

Commercial payers have all posted their interpretation of preventive care-and all say that preventive care is a service provided in the absence of disease and symptoms. ICD-9 also tells us that in the presence of a symptom or diagnosis, we cannot code a screening code.

This has become a hot topic, because patients misunderstand the concept of preventive care, and to make matters worse, customer service people at the insurance company are suggesting to the patient that their claim would be paid if it is 'coded correctly'. That's insurance-speak for "we don't want to take responsiblility for let's blame the provider office". I've personally addressed this with the payers in our area, and you may need to do this as well.

As certified coders, we are expected to code correctly and appropriately, based on the coding guidelines set forth, in this case by CMS and WHO.