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Preventive plus sick

  1. #11
    Location
    Duluth, Minnesota
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    Exam Training Packages
    well, good luck with that - let me know how it turns out...
    *shrugs* it just doesn't get any clearer to me, and I don't know how to explain any other way.
    but if you know the difference between new and established - and guidelines that have to be followed,...then you should be able to see that you can't bill a patient two new patient services in the same day for the same provider or same specialty/group. *shrugs*
    Last edited by dmaec; 02-02-2009 at 07:14 AM.
    Donna, CPC, CPC-H

  2. Default
    The statement below seems to support that a 99385 and 99201 can be coded for the same visit (preventive with sick). The statement is 99201-99215. Doesnt that mean 99385 + 99201 or 99395 + 99212 with new/new or est/est?

    Anybody have a clear statement on this in writing?

    Per CPT guidelines, ..................then the appropriate office/outpatient code 99201-99215 should also be reported.

  3. #13
    Location
    North Carolina
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    I do agree that the guidelines state you can bill new or established E/M codes with a PE but I really think this can become carrier specific.

    UHC-Preventive Medicine services include annual physical and well child examinations, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes only--99201-99205 or 99212-99215--when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

    As you can see...UHC is one of our carriers that do allow this.

  4. #14
    Location
    Duluth, Minnesota
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    1,133
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    key word is appropriate
    per guidelines, you can't be new if you've already been seen by that provider or another of same specialty/group (and you're coding out the preventive service as a NEW patient) - then you've Established that patient by coding the initial service as new... so that being said, the appropriate code to use on the E/M is esablished.

    (k, I almost didn't post again - but now I'm done cuz I just can't make it any clearer) it seems quite obvious to me and I apologize at my inability to explain any further)
    Donna, CPC, CPC-H

  5. #15
    Location
    Jacksonville, FL River City Chapter
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    74
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    Donna,

    The theory that performing the preventive medicine service causes the patient to become established in-between the preventive service and the problem-based service is interesting, but incorrect. Note that the notes preceding the Preventive Medicine codes indicate that a problem-based encounter performed with a preventive medicine service is coded from 99201-99215.

    The fact that the new patient (99201-99205) codes were included as possible codes used to describe the problem- based visit shows that your theory about the patient becoming established in-between the two services is not valid. If that were true, the new patient codes would never be used with a preventive medicine service.

    The question as to how to code a new patient receiving both a preventive service and a problem-based E/M at the initial encounter was asked of the AMA. They responded, in the October 2006 CPT Assistant:

    "...if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

    If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate)."


    Seth Canterbury, CPC, ACS-EM
    Last edited by SCanterbury; 01-30-2009 at 03:28 PM.

  6. #16
    Location
    San Gabriel Valley
    Posts
    31
    Default preventive and sick same day
    refer to the CPT book under the preventive codes read the guidelines. It gives the information there.

  7. #17
    Location
    North Carolina
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    Sbicknell...

    Do you feel better about coding these now?

  8. #18
    Location
    San Gabriel Valley
    Posts
    31
    Default new prevenitve and new sick
    We came across this issue before. You could code both new, but if you literally take the guidelines you should code New for the preventive if patient made an appointment for a preventive then the MD has documentation to support the sick visit.
    Some of our physicians feel they are new to them when doing a the preventive and then is considered established when they perform the sick.
    Hope this helps. I have instructed staff to review the appointment and code accordingly. The patient will be responsible with two co-pays.

  9. #19
    Default new PE & sick same day
    I can tell you that from a commercial follow-up perspective I see denials in 2 situations often:
    1. Both PE & sick billed as new
    2. sick billed as new and PE billed as established

    Either way produces the same result - the PE visit pays, and the sick visit denies as "new pt code billed for an established pt".

    My best guess as to why this happens is that since the sick visit is "additional work" beyond the PE, the PE is considered the "primary" procedure of the 2, and processes "first". If you bill it as established, then they'll pay it as established, but when they get to the sick visit, they've already decided that the patient is established, so they won't pay it.
    If the PE was billed as new, then they'll pay it, but they definitely won't pay more than one new pt code for the same practice/specialty (unless it's been over 3 yrs, of course).

    So the only situation that seems to work is
    New PE + Established Sick E/M (w/25 mod) = no denial.

    It's an easy way to justify paying less overall for both procedures, and to deny one of them whenever possible. It would be nice if the CPT book were a little more specific on the issue though.

  10. #20
    Location
    North Carolina
    Posts
    3,126
    Default
    I agree that billing for a new wellness/new problem oriented visit poses some hurdles for reimbursement but if the guidelines are met, they are billable. Depending on the carrier...payment, for both (new), may be another story. CPT Assistant does provide guidance on this and if an appeal was in order, this could be referenced.

    Excerpt from 10-2006

    Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    Therefore, if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

    If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate).

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