Question Preventive visit with office visit

Boyz18

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Can someone please guide me to the rules of billing an office visit with modifier on top of a preventive (annual wellness) exam? Thanks
 

DeBillingTater

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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.
 

Pathos

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One big thing to keep in mind when combining a preventive visit with a problem visit is cost. If the patient believes he/she is coming in for a "free" preventive visit, and then gets slapped with a bill for the Problem portion of the visit, then they often get irate. Good business practice could be to notify the patient first before getting into the problem focused portion of the visit, so they are at least aware and have a chance to accept or reschedule.

While Correct Coding can allow it, consider performing excellent customer service and get ahead of any possible future patient complaints.

Also, combining E/M with a preventive is often payer based, just like Rhonda mentioned.
 
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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.
 

Pathos

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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.
 
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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.
Would you include the behavioral health as part of the preventative, or have them come in for a BH visit just to do the assessment?
 

Pathos

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That would depend on the BH part, but if it's a Well Child visit and part of the BH screening, then you could probably bill the tests separately (as appropriately). I would still pause to bill both an E/M and Well Child preventive visit for what you have described above.
 

Boyz18

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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.
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?
 

DeBillingTater

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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?
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.
 

jademound

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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 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.
 

Pathos

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As part of the preventive visit, it is expected to adjust any medications on chronic and previously stable conditions. A simple Rx change is not sufficient for a significant and separate E/M to cover that work. This work is considered bundled into the Preventive Annual Visit code.

Based on the information provided by Boyz18, the annual preventive visit code should be billed (assuming everything else is supported by documentation), but no extra E/M to cover the Rx change.
 

tpgrice

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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?
 

Pathos

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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?
Can you share your reference source on this information?
 

tpgrice

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Unfortunately, i do not remember where i read it. That is one reason that i am getting AAPC's view on it.

I just need to educate my providers on the correct way to handle these in the future. I would really appreciate some input. Do we code to the chief complaint (in this case a physical) or do we code for the E&M because there were refills given on a stable condition as well as labs done?

In my opinion, if the visit was scheduled as wellness, the chief complaint is listed as a wellness, and the patient expected the visit to be a wellness... then the practice is at fault for not educating the patient otherwise. The physician/nurse, merely needed to tell the patient that if refills are needed and maintenance labs are done, then the patient would need to return.
 
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