Wiki Routine Physical & 99213 same day

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I'm looking for some advice on coding routine & sick visit on same day. If a patient comes in for an annual exam & doc mentions history of hyperlipidemia, hypertension, colonic polyps & CAD in the HPI. He then proceeds with exam & renews 3 meds for patient. Would this warrent a visit also or is it part of the routine. Another situation was the patient had meds renewed but no mention in the HPI or exam. We are trying to establish a solid criteria to follow so any advice is helpful.
 
If the patient schedules an annual then that is the visit. To evaluate the chronic conditions is part of the annual. To charge the office visit in addition, the patient must be the one to "initiate " the office visit by stating a complaint , such as a symptom that requires attention. In the case you have stated the only visit requested by the patient is the wellness .
 
Routine & 99213

Debra, thank you for your response. It gives a clear picture!
 
Not necessarily, CPT Assistant highlights an example very similar to what you've described above - and they use it to illustrate an instance of when it is appropriate to bill for a routine preventive visit AND an office evaluation and management service on the same day. Here I'll paste it for you:

CPT Assistant:
Family Practice and Internal Medicine
A 55-year-old established male patient presents to the
physician's office for periodic preventive medicine
reevaluation and management. The patient has
established diagnoses of hypertension, on beta blocker
therapy, Type II diabetes controlled with sulfonylurea,
and chronic stable angina controlled with sublingual
nitroglycerin as needed.

A comprehensive history and examination are
performed as part of the preventive medicine service.
Furthermore, a specific history is taken and further
examination is performed regarding the established
diagnoses as listed above.

To report this, CPT code 99396 would be used for the
preventive medicine services visit. In addition, the
appropriate problem oriented level of E/M service would
be selected based on the key components associated
with providing the problem oriented E/M service.
Click to expand...

CPT Assistant
Pediatrics and Family Practice
A woman brings her 3-year-old son, established patient, to
the physician's office for annual health supervision and
evaluation. During the preventive medicine encounter, the
physician notes inflammation of the right middle ear. Upon
further questioning, the mother recalls a two day history of the
child pulling at his right ear. He has been irritable, running a
low grade fever, coughing, and has had difficulty sleeping at
night. The physician then (additionally) performed the key
components of a problem-oriented evaluation and
management service.

Appropriate laboratory tests were ordered. Antibiotics were
prescribed and a follow-up visit was scheduled. The
physician diagnosed acute right otitis media, acute tonsillitis,
and acute adenoiditis.

To report this, CPT code 99392 would be used for the
preventive medicine services visit. In addition, the
appropriate problem oriented level of E/M service should
be selected based on the key components associated
with providing the problem oriented E/M service.
Click to expand...



Here's an excerpt from the CPT E/M Section Guidelines

The “comprehensive” nature of the Preventive Medicine
Services codes 99381-99397 reflects an age and gender
appropriate history/exam and is not synonymous with
the “comprehensive” examination required in the evolution and management (E/M) codes 99201-99350. Codes
99381-99397 include counseling/anticipatory guidance/risk
factor reduction interventions provided at the time of the
initial comprehensive preventive medicine examination or
periodic re-evaluation. (Codes 99401-99412 are used for
reporting counseling/anticipatory guidance/risk factor reduction interventions provided separately from the preventive
medicine examination.)

If an E/M service code (99201-99350) is reported in addition to a code from the 99381-99397 and/or 99401-99412
series, modifier 25, Significant, separately identifiable E/M by
the same physician on the same day of the procedure or other
service, should be appended to the appropriate level E/M
service code. Modifier 25 is reported to indicate that on
the day a procedure or service identified by a CPT code was
performed, the patient's condition required a significant and
separately identifiable E/M service above and beyond the
other service provided. A significant, separately identifiable
E/M service is defined and/or substantiated by documentation that satisfies the relevant criteria for the respective E/M
service to be reported.
Click to expand...
 
Last edited:
Mike, that is great information. Is there some type of guide you would recommend when performing a routine/wellness visit? I'm trying to give our providers a solid distinction between routine requirements and sick visit so we have something solid to go by. The provider in one situation mentioned the 3 chronic problems in the HPI and renewed meds but I feel did not perform exam specific to problem. I know we only need 2 out of 3 key components but I just did not feel it warranted a sick visit code. Any advice?
 
There is no specific documentation requirements that I know of for a routine preventive visit. It just says there should be an "Age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures"

In my experience as an auditor, it's usually difficult to pull out anything from the exam (since it's already part of a routine physical) but when I see someone billing a "combo visit" for example a 99392 with a 99213-25, I try to highlight elements of the history that are specific to the problem(s), then I do the same in the MDM. Since only 2/3 key components are needed, that's usually enough.

As my rule of thumb, if the stuff that I highlight and separate out from the CPE is only sufficient for a 99212 - I tell them they shouldn't be billing it. By definition that's a straightforward issue, and the incidental findings should not be billed separately. On other other hand if it's a level 5, you generally shouldn't have a "well visit" on the same day, since those issues are so acute and severe that they really aren't well. Maybe reschedule them for when they are feeling better. That's not ALWAYS the case, sometimes it is appropriate, but that's my rule of thumb. So generally if you have a "combo visit" it's going to be a CPE with a 99213-25 or a 99214-25.
 
Two E&M visits same day

Mike, I really appreciate the information. You have given me a much better understanding and I feel confident in creating guidelines for our facility! I have one more question that I would appreciate your direction on: If a patient is seen in our office in the morning & the physician does all the proper documentation for a problem, i.e. 99214. He then sends to our other location for an MRI. Another physician at the other location then does a follow up with results of MRI and MDM etc. Both are PCP's and 2nd doc did 99214 also. Will both services be considered with a 25 modifier?
 
I don't see why a modifier -25 would be needed in this scenario. Here's the definition of modifier -25, and I've bolded the key part here:

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

....since your scenario has a different provider performing what I assume is a medically necessary evaluation and management service, there's nothing wrong with billing them both. No modifier needed.
 
Now here is the problem.... ICD-10 CM, You need to look at the Z00.0x, Z00.1x, Z01.4xcodes for the general exams (the equivalent to the V70.0, the V20.0, and V72.31)
These codes all have an excludes 1 note (pure exclusion) for signs and symptoms. Which means signs and symptoms cannot be coded with the general exam codes. So between now and Oct. 1 2014 you need to decide how you will handle this, also the codes state general exam without complaint, suspected, or reported diagnosis. Therefore you cannot code with the chronic conditions such as the hypertension etc, and therefore you will not be able to charge an additional encounter to discuss the chronic conditions.
 
Hi Mike, I just want to mention that the visits were done by physicians of the same specialty in the same group. This same situation happened before and the insurance denied stating duplicate service and they insisted on corrected claim with modifier. I agree with you that documentation should substantiate services. We would love to have someone like you lecture at one of our AAPC meetings!! Would you ever consider coming to New York? Thank you again for sharing insight on these issues!!

Debra - We are starting to get a grip on ICD-10 issues and thank you for the heads up on the routine v codes.

Deb
 
By the CPT definition, a modifier isn't needed. Of course, insurances may have their own rules so all I can really highlight is "coding theory" - when it comes to the real world you may have to add the modifier to get paid. My guess is the insurance is accepting the claims electronically and they are seeing the same Patient ID, DOB, Date of Service, and Tax ID and it's flagging as a duplicate claim that would require a modifier. Ideally they would realize that the NPI of the rendering provider is different, but maybe you are set up to bill under the group NPI so in that case they will need a modifier.

Thanks, New York might be a bit tricky for me. As it is I work 2 jobs and have a little one so even though I'd love to speak with you guys I'm not sure when I would have time. Maybe over the summer. Or if you wanted to do a webinar that would be easier for me. Just sent me a PM or an email (my website/contact info is in my signature)
 
We would love to have you speak over the summer or even webinar would be great. We have to try to arrange something. Sounds like you are really busy!!! At the risk of asking too much, maybe you can answer 1 more question that no one else can? We have a internal med doc that sees some children. We recently have a new pediatric doc that joined our group. Some of the children have decided to move to the pediatric doc. He would like to know if we can charge a new patient since it is a different specialty in the same group. But I was not sure because it is almost like a lateral move from PCP to specialty pcp? Any suggestions?
Deb
 
Hi Deb,
I would advise to just bill those as established patients, although technically you might get away with it if you bill them as new.... I wouldn't advise it. Even though the specialties are different, the are really being seen in the same group for the same purpose (primary care.) I would treat it differently if the other doc had a very unique sub-specialty which explains why he/she is seeing those patients (sub-specialty in behavioral disorders or something like that)
 
Physical and OV

My office manager is not sure why but we keep getting the same denial from Medicare that when we charge for a preventative exam and an office visit, we append modifer-25 and still get the denial. We send records for appeals and they still deny saying that the service is not significant separately identifiable services.
Can anyone tell me what can we do from here?
 
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