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Billing High Level EM in place of well check

  1. #1
    Default Billing High Level EM in place of well check
    Medical Coding Books
    Is it appropriate to bill a high level EM 99215 in place of a well check if the provider feels that it took lots of time etc due to complexity of pt. This Specific payer doesn't allow two EM codes of well and sick to be billed. Charting is predominantly well and ap has well listed as secondary or tertiary DX code. Would this be allowed if doctor wanted to document time based coding

  2. #2
    Columbia, MO
    It would be appropriate if the provider documented an abnormal finding and investigated the finding. Then you could bill the preventive dx code plus the abnormal finding, and use the high visit level with the 33 modifier. If the only thing you have is a lengthy annual with no abnormal,finding then no you cannot convert the encounter to a high level visit.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default Billing high level E&M in place of a well child check up
    It is not appropriate to bill that way. If a payer such as Medicaid doesn't allow the billing of an additional E&M visit on the same day as a wellness visit then the findings during that vist will be included in that wellness visit. It is nor appropriate to submit dx V20.2 with any E&M codes other than the preventive cpt codes established for that dx. However, you may list the additional sick dx based on the findings from the preventive visit as 2nd, 3rd, 4th etc..Although, the preventive visit may have been lengthy and abnormal there are still quality measures that have to be billed and submitted annually for mos payers which are normally captured at the time of the AWV such as your HEDIS measures. Most government payers and several commercial payers expect providers to perform AWV of their members regardless if the payer would allow or pay for additional E&M on the same day or not. Therefore, the provider should document his findings order the necessary test prescribe the necessary meds and bill the age appropriate preventive code with the V20.2 dx as primary and all others following in the order of the highest complexity. Then reschedule that patient for a f/u to manage the new conditions dx from the preventive visit.

  4. #4
    Columbia, MO
    Yes it is appropriate to bill this way, the 2010 dec CPT assistant confirms this, it is unfortunate the code example was different but if you read the narrative of that issue it will,support this. The 33 modifier supports that this is a preventive measure with a diagnostic finding. If however there is no abnormal finding documented then I agree you do not bill this way.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Thank you both. Now I will add another layer. The specific payer has a clause that States if pt presents for a well check a predominantly well exam etc are done and you find other issues you are to still bill the well a primary purpose of visit. Will the modifier if used still let visit be tracked for Hedis purposes or is mod 33 payer specific?

  6. #6
    Columbia, MO
    The 33 tells the payer the service meets the preventive task force definition of a preventive service. But remember there must be documentation of an abnormal finding. And yes it it to be captured as a preventive encounter. I have had to appeal a few but it has worked.

    Debra A. Mitchell, MSPH, CPC-H

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