Questioning Ethics of What I'm Coding

urbach34@yahoo.com

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I code for a PCP who constantly bills AWV (G0439) with sick visits (99213). I truly feel patients are coming in for their sick visit and he is seeing that it has been over a year since their last AWV, so he goes ahead and tacks it on. I'm not in the office, so I'm not there to see the work that is being done. Maybe he is, in fact, doing all of the work he is billing for, but I thought that a patient had to be scheduled for their AWV. Can someone please clarify this for me? Are there guidelines somewhere that clearly explain what is proper in this situation? I understand that I am able to bill this, I have not gotten any denials on anything. I'm just concerned that it's not ethical. I feel like it's "up selling" the patient on a service they didn't request.
 
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mitchellde

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Read the codes for ICD-10 CM the wellness diagnosis is in category Z00 which states without complaint, suspected or reported diagnosis, and the exclude 1 notes states that encounters for signs and symptoms are exclude 1 excluded and you are to code to the signs and symptoms. Also the instructions in the CPT book under the preventive codes states that you can bill an additional office level using the 25 modifier if the provider discovers an abnormality or a problem with a chronic problem thT requires additional study.
 
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Ethics

I code for a PCP who constantly bills AWV (G0439) with sick visits (99213). I truly feel patients are coming in for their sick visit and he is seeing that it has been over a year since their last AWV, so he goes ahead and tacks it on. I'm not in the office, so I'm not there to see the work that is being done. Maybe he is, in fact, doing all of the work he is billing for, but I thought that a patient had to be scheduled for their AWV. Can someone please clarify this for me? Are there guidelines somewhere that clearly explain what is proper in this situation? I understand that I am able to bill this, I have not gotten any denials on anything. I'm just concerned that it's not ethical. I feel like it's "up selling" the patient on a service they didn't request.

It is the state medical board that oversees physician conduct and of course, the payers track billing patterns and patient complaints. However, it sounds like the physician is doing just what CMS has requested - https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ in encouraging (and making convenient) receipt of the preventive services. I doubt there is anything unethical about providing services that are appropriate (lawmakers determined appropriateness by creating the AWV benefit and many components of the service are based on clinical guidelines) if the patient is agreeable to receive them. As long as all elements including the health risk assessment are completed, the wellness visits should be billed in addition to any significant sick visit. The time and effort to provide the AWV are not insignificant but there are many reasons to offer the services. Many Medicare patients do not otherwise receive general health information and recommended preventive services that may help them maintain or improve their health because the focus has been only on chronic conditions and acute care. Physicians are also under pressure to show quality care with many quality measures included in the components of the AWV (eg, assessing fall risk, depression screening, BMI).

It is good to have concern for the patients but I don't think you should be concerned based on the information provided.

Cindy
 

urbach34@yahoo.com

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Cindy,

Thank you for your feedback. I've never had anyone explain it to me in those terms and that does put my mind at ease. I've always been under the impression that we shouldn't be doing the AWV unless the patient came in requesting it, but it does seem logical that it is more convenient for the patient to provide the service while they are already there, rather than make them come back on another day. I appreciate your input, and do feel better now.

Thanks!
 

mitchellde

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However for ICD-10 CM coding it is not compliant to code a well visit Z00 with a symptomatic encounter. You must read your ICD-10 CM rules. If the patient presents for problems and or complaints then you cannot decide to also decide to perform a wellness visit, nor can you provide one at the patient request. Unles or until this is changed from Oct 1 2015 and forward you cannot code and charge a wellness with a sick visit unless the provider documents that the patient had no complaints or concerns and discovered something during the well exam.
 
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