Our Pediatricians bill all the time an office visit with preventative for the following, behavioral health, birth control(new rx and refills), and they bill a level 4 visit since they think prescription management always bills at a level 4 per their blogs and threads they have online.
If the preventive visit was to check up on the patient's stable conditions and go over medication (Rx management), then this is part of the preventive visit. Anything significantly new can possibly go towards an E/M (like the sore throat mentioned above).
The problem I see with billing a preventive and problem focused visit is when it comes to carving the note out, and double dipping. I do understand the argument to allow the patient to have their other problems addressed during the preventive visit, but be careful to not use a section/portion of the visit towards both codes. Remember that a big part of the preventive visit is to reconcile or visit the patient's medication list and ensure everything is appropriate. This becomes tricky when the Rx list includes drugs that are used towards the problem focused visit. I do get concerned when providers bill a higher level E/M (992x4-5) with a Preventive visit. It is possible if documentation and medical necessity supports both, but requires really good documentation to ensure both codes are properly supported.
The commercial payers who accept both, often use multiple procedures reduction which reduces the reimbursement on either the E/M or preventive visit. The practice I used to work for flat out decided to only bill the code 50% or more of their time was spent on, or simply have the patient reschedule for their problem visit, but that was just their billing practice.
What about example - pt comes in for annual visit. BP is a little high so doc decides to increase BP med without patient complaining about it. No other complaints. Does this warrant the additional work for the provider to bill the office visit in addition?For commercial payers, the annual visit incorporates all stable, chronic, etc conditions. An office visit with a mod 25 would be appropriate should they be seen for anything more.
Example: Pt comes in for annual visit. Everything is great, diabetes management is fine. Pt complains of sore throat/cough and that is addressed during visit.
An annual would be billed, and office visit would be appropriate to be billed.
Example 2: Pt comes in for annual visit and wants to discuss birth control options/annual STD testing, office visit not applicable here. Annual would be billed only with any appropriate testing codes, etc.
Apologies for such a late reply. In that case, it's a pretty grey area. As long as the condition of the patient was stable with no complaints, you could argue that it is a preventative only with brief review of a chronic condition. If the patient's condition was managed and had consistently normal BP with his meds, and then the BP is suddenly higher warranting a closer look, then that could possibly be billed as a 99212 as it is an "emerging" issue with low complexity and low decision making in relation to the condition.What about example - pt comes in for annual visit. BP is a little high so doc decides to increase BP med without patient complaining about it. No other complaints. Does this warrant the additional work for the provider to bill the office visit in addition?
What about example - pt comes in for annual visit. BP is a little high so doc decides to increase BP med without patient complaining about it. No other complaints. Does this warrant the additional work for the provider to bill the office visit in addition?
I apologize but i am getting conflicting information. I read in one place " During a complete physical or annual exam, time is spent managing ongoing conditions and medications, addressing new concerns, and reviewing risk factors. A longer appointment time allows for necessary vaccines, tests, cancer screening / recommendations, review of family history, counseling, etc." and in another " A complete physical or annual exam in which ongoing medical problems are addressed or prescriptions are renewed, or in which one or more complaints are evaluated and treated, cannot be billed as a “wellness check.” Routine co-pays and deductibles will apply. Is this dependent on the insurance, the biller, or the patient? What is the AAPC's take on this?
Hi all,For this example, I do not feel a separate E&M is warranted. The patient is not complaining of an additional issue. Had the patient been scheduled for an annual exam, but then also came in with the complaint that they haven't been feeling well (light-headed, etc) and the provider performed additional work-up and determined the cause to be the increase in BP, then yes, an additional E&M would be warranted. A simple medication adjustment for a chronic condition isn't separate and significant.