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Thread: Well exam with a re-exam...

  1. #1
    Join Date
    Apr 2007
    Chicopee, MA

    Default Well exam with a re-exam...

    AAPC: Back to School
    We bill for an internal medicine group. The office manager there has been reviewing the office notes on all routine physicals and if the doc reviews any other symptoms, ie HTN, Wgt gain, Diabetes...and so on..., she sends the fee slips back and advises them to add a separate E&M (99212-99214) with modifier 25. After seeing numerous physicals come through this way, we asked to see the office notes so we can review before sending to insurance. After reading all the notes, we have come to the conclusion that we totally disagree with the office manager. In almost all cases, the patients clearly presented for a physical. Some discuss an underlying problem or concern, but almost all have no follow up or diagnostic testing done. I have been studying for the CPC, and just took my exam last week. But, it is my understanding that a separate E&M can (and should) only be billed if there is a completely separate work-up done at the time of service with a course of action for treatment to follow. The office manager strongly disagrees with me. Does anyone know of a good source of documentation to help me, or her, understand this better?! I don't want the docs to be misinformed by either one of us!

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    I am not sure this will help but it may be a start.. it is an except from the coding guidelines on administrative exams
    Routine and administrative examinations
    The V codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.

    So just because the patient has a cronic dx as long as there is no symptomatic problem then it is still all for the preventive exam. Look on the AMA website as they have had some very good articles on the issue of split visits.

  3. #3

    Default Preventive Medicine Services


    According to the notes preceding the preventive services codes 99381-99397in the 2009 professional edition of the CPT "if an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing the preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should ALSO be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service is additionally reported.

    An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported."

    In other words, if the problem reported during a screening is warranted enough for the doctor to document the history, perform a physical exam, and alter Medical Decision Making regarding the problem and there is documentation in the file to justify this service, then by all means it is reportable as a separately identifiable E/M service at the time of a preventive E/M service. You can bill for both the Office Visit and Preventive Service but remember to add modifier 25 to the Office Visit code. Remember that documentation is key. The golden rule to accurate coding is "if it is not documented, it did not happen."

    I hope this helps.

    Scott Norman, MSEd., CPC
    Americare School of Nursing

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