Wiki Preventative with an E/M

Create Wiki
R

rmness

Networker
Messages
26
Location
Fargo
Best answers
0
There is debate in my office regarding what can and cannot be split out from a preventative visit and billed as an additional problem E/M. I am being told that we should only split out any conditions that are new, worsening, there is a prescription change, or a new treatment is initiated.

I disagree as per CPT guidelines, "If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management service, then the appropriate" E/M should be reported (paraphrased this part).

For brevity's sake I did not paste the exam and other portions of the note. All documentation needed for the preventative exam was performed. Here is an example of a note we disagreed on split billing:

HPI / History / ROS
63 year old female who I see today for annual exam. Overall she is doing quite well. No major concerns. She continues to recover from her stroke. It has been over a year. She is back to doing some of the things that she used to do including cooking. Still has some struggles at times. A1c is up to 7.2. On Rybelsus and metformin.

Assessment / Plan
Routine health maintenance

Need for vaccination
- TDAP (BOOSTRIX) IM VACCINE - 7 YEARS AND UP
- PNEUMOCOCCAL 20 (PCV 20) IM VACCINE 18 YEARS AND UP

1. T2DM. On Rybelsus and metformin. A1c 7.2. Consider switching to Mounjaro if covered by insurance from the Rybelsus.

2. Depression/anxiety. On celexa, buproprion and hydroxyzine. Stable.

3. Peripheral neuropathy. Stable. Continue gabapentin.

4. Hypothyroidism. TSH at goal. Continue levothyroxine.

5. HLD. Lipid panel reviewed and looks good. Continue rosuvastatin.

6. Health maintenance. Age appropriate HM concerns addressed. Due for colonoscopy in 2032

7. OSA. Uses CPAP. Benefits and should continue.

Follow up in 6 months.

To me, if a condition is being listed in the assessment and plan, the status of the condition is listed, and the treatment (continue med) is documented, it would be appropriate to report the additional problem E/M as it meets medical decision making requirements.

What is correct? If you agree to split bill, which conditions would you split out?
 
ok, I am not an expert and here is my thought. You said you have all documentation for preventive service and now you show us documentation for possible E/M. To me, there is unrelated , significant service provided to the pt where MD is assessing pt's (unrelated to preventative service) chronic conditions AND medicine management. DX for E/M, I would choose- E11.9 + Z-codes for meds, #2-#5, #6. These are chronic conditions that MD re-assessed and reviewed corresponding medications (continue, switch etc). I guess level 4? stable chronic dx with meds management= both columns are moderate= 99214.
 
rmness said:
There is debate in my office regarding what can and cannot be split out from a preventative visit and billed as an additional problem E/M. I am being told that we should only split out any conditions that are new, worsening, there is a prescription change, or a new treatment is initiated.

I disagree as per CPT guidelines, "If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management service, then the appropriate" E/M should be reported (paraphrased this part).

For brevity's sake I did not paste the exam and other portions of the note. All documentation needed for the preventative exam was performed. Here is an example of a note we disagreed on split billing:

HPI / History / ROS
63 year old female who I see today for annual exam. Overall she is doing quite well. No major concerns. She continues to recover from her stroke. It has been over a year. She is back to doing some of the things that she used to do including cooking. Still has some struggles at times. A1c is up to 7.2. On Rybelsus and metformin.

Assessment / Plan
Routine health maintenance

Need for vaccination
- TDAP (BOOSTRIX) IM VACCINE - 7 YEARS AND UP
- PNEUMOCOCCAL 20 (PCV 20) IM VACCINE 18 YEARS AND UP

1. T2DM. On Rybelsus and metformin. A1c 7.2. Consider switching to Mounjaro if covered by insurance from the Rybelsus.

2. Depression/anxiety. On celexa, buproprion and hydroxyzine. Stable.

3. Peripheral neuropathy. Stable. Continue gabapentin.

4. Hypothyroidism. TSH at goal. Continue levothyroxine.

5. HLD. Lipid panel reviewed and looks good. Continue rosuvastatin.

6. Health maintenance. Age appropriate HM concerns addressed. Due for colonoscopy in 2032

7. OSA. Uses CPAP. Benefits and should continue.

Follow up in 6 months.

To me, if a condition is being listed in the assessment and plan, the status of the condition is listed, and the treatment (continue med) is documented, it would be appropriate to report the additional problem E/M as it meets medical decision making requirements.

What is correct? If you agree to split bill, which conditions would you split out?
Click to expand...
I agree. Clearly the diabetes was assessed and a new prescription drug management option considered (not required but clearly indiciative of MDM not included in a preventive E/M). Cindy
 
natashalage said:
ok, I am not an expert and here is my thought. You said you have all documentation for preventive service and now you show us documentation for possible E/M. To me, there is unrelated , significant service provided to the pt where MD is assessing pt's (unrelated to preventative service) chronic conditions AND medicine management. DX for E/M, I would choose- E11.9 + Z-codes for meds, #2-#5, #6. These are chronic conditions that MD re-assessed and reviewed corresponding medications (continue, switch etc). I guess level 4? stable chronic dx with meds management= both columns are moderate= 99214.
Click to expand...
Thanks so much, I also get moderate for problems due to multiple chronic conditions and moderate risk for the rx mgmt which would be a level 4. I think I've found a webinar that will also be helpful to present to the others.
 
Think of it this way:
If you printed the note and took a pen and crossed out everything related to the preventive visit, what is left? Is it enough to bill an E/M and support modifier 25?
The documentation must support the billing of both codes and modifier 25.
From your note snip above, it is difficult to tell if this provider is managing all of those numbered problems or just listing them out. This documentation is poor, pretty weak support for a 25 Modifier and a separate E/M. I see: "Overall she is doing quite well. No major concerns." Would this patient have come in other than for the preventive? What is wrong? There's just a med list and a bunch of stable problems listed. It states the A1C is up, but what was it before? Nothing is documented. Is the DM worse, is it better? Yes, it says consider Mounjaro but why? Any data review, test & documents? Is the peripheral neuropathy related to the DM? If the TSH is at goal, where is the lab result? Where is the A1c lab? Is this a Medicare patient?
Most health plans have written policies on it as well that you could refer to.
Health plan examples:

Other links (check dates and do your own research as well):
https://www.ama-assn.org/practice-m...ll-both-preventive-and-em-services-same-visit https://www.ama-assn.org/system/files/regulatory-myths-e-m-coding-billing.pdf

CMS:
"When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part."

You can also search the forums here on the top right for key words for other info about it:
Example: https://www.aapc.com/discuss/thread...-office-visit-on-same-dos.198220/#post-552130
 
amyjph said:
Think of it this way:
If you printed the note and took a pen and crossed out everything related to the preventive visit, what is left? Is it enough to bill an E/M and support modifier 25?
The documentation must support the billing of both codes and modifier 25.
From your note snip above, it is difficult to tell if this provider is managing all of those numbered problems or just listing them out. This documentation is poor, pretty weak support for a 25 Modifier and a separate E/M. I see: "Overall she is doing quite well. No major concerns." Would this patient have come in other than for the preventive? What is wrong? There's just a med list and a bunch of stable problems listed. It states the A1C is up, but what was it before? Nothing is documented. Is the DM worse, is it better? Yes, it says consider Mounjaro but why? Any data review, test & documents? Is the peripheral neuropathy related to the DM? If the TSH is at goal, where is the lab result? Where is the A1c lab? Is this a Medicare patient?
Most health plans have written policies on it as well that you could refer to.
Health plan examples:

Other links (check dates and do your own research as well):
https://www.ama-assn.org/practice-m...ll-both-preventive-and-em-services-same-visit https://www.ama-assn.org/system/files/regulatory-myths-e-m-coding-billing.pdf

CMS:
"When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part."

You can also search the forums here on the top right for key words for other info about it:
Example: https://www.aapc.com/discuss/thread...-office-visit-on-same-dos.198220/#post-552130
Click to expand...
Thank you, thank you, thank you for these multiple wonderful resources!
 
You must log in or register to reply here.
Top