Question Physical Coding

griffind3

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Patient has BCBS insurance, they were seen by the practice GYN for well woman coded 99386 without PAP completed. 2 months later patient comes and see the family provider for an annual physical coded 99396. However, both providers are under the same Office just one is a GYN other is Primary. The patient came in a a new patient in the beginning of the year. My question is will the most recent with the primary 99396 annual physical is covered by insurance or will it need to be changed to a E&M code? Please advise.
 

SharonCollachi

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Whether it is an ob or a pcp is irrelevant. Whether it is the same group or not is irrelevant. If the patient had a preventive visit, and their insurance covers one preventive visit per calendar year, then the second one will not be paid. I will not tell you to change the code to get it paid. If the patient had two preventive visits, then that's what they had, and that's how it should be coded.
 

csperoni

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I disagree with Sharon's first 2 statements (rare instance :).) Most insurances will allow for a preventive with primary care AND a preventive with ob/gyn, even if part of the same large group under same TID. It may initially get denied, but an appeal letter explaining different types of exams by different types of physicians will typically get it paid.
I totally agree with Sharon's other advise. You should not code a visit for anything other than it was, regardless of whether or not it would be covered by insurance.
If it denies, and an appeal letter does not get it paid for the reason that the insurance plan will only cover 1 preventive per year, then the patient may be billed and you need to make a business decision about how to handle it. My personal opinion of best practice is that the patient should have been informed prior she might owe if you thought it would be an issue. Advance notice is not required, but a good practice.
 

SharonCollachi

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I disagree with Sharon's first 2 statements (rare instance :).) Most insurances will allow for a preventive with primary care AND a preventive with ob/gyn, even if part of the same large group under same TID. It may initially get denied, but an appeal letter explaining different types of exams by different types of physicians will typically get it paid.
I totally agree with Sharon's other advise. You should not code a visit for anything other than it was, regardless of whether or not it would be covered by insurance.
If it denies, and an appeal letter does not get it paid for the reason that the insurance plan will only cover 1 preventive per year, then the patient may be billed and you need to make a business decision about how to handle it. My personal opinion of best practice is that the patient should have been informed prior she might owe if you thought it would be an issue. Advance notice is not required, but a good practice.

I have personally had health insurance policies only allows one preventive per year, period. So what I was trying to say is that the policy may not allow it. That's the first thing to check.
 
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