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Medicare Advantage Plans-Problem visit w/annuals

  1. #1
    Default Medicare Advantage Plans-Problem visit w/annuals
    Medical Coding Books
    If a patient has a MedAdvantage plan that covers annual exams, do they follow the same guidelines as Medicare? Medicare states the problem visit can be subtracted from the annual exam price and the pt's charged the difference to cover the work above & beyond the problem visit. For a Medicare pt, we can support a 99214 since whatever's left over goes to the annual. For a commercial payer, the annual would be the first charge and whatever's left over would go to support the problem visit. Unless their guidelines prohibit it, they would pay both, since they would expect there to be 2 separately identifiable charges documented. In this case, we wouldn't be able to support a 99214 since much of the history (non-problem related ROS & PFSH) would already be accounted for in the Annual charge.
    So, would MedAdvantage plans expect the documentation to look like Medicare's (office visit subtracted from a/e) or like a commercial's requirements (office visit separate from a/e)? I'd appreciate any insight. Thanks!
    Sue Vermette, CPC, CPMA

  2. #2
    Seacoast- Dover New Hampshire
    I use a 25 and do not carve out the visit.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Charleston, South Carolina

    Medicare Advantage plans must be equal to Medicare. They can have other benefits as well, but at the minimum they must provide the same services that Medicare does.
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

  4. #4
    Default Audit Worries
    Thanks for the responses. My concern is that if the Medicare Advantage audits us, would we have to support both the 99214 and 99397? If Medicare audits, we would only need to support the 99214 since it's the only service covered (and paid) by Medicare. If Medicare Advantage audits us, would they expect to see documentation for a full 99214 AND a full 99397 if they pay for both? If this is the case, we would only be able to support one charge, so I'm thinking we shouldn't bill for both. This would complicate things because we'd have to change our coding depending on what type of Medicare plan they have. Any suggestions?
    Sue Vermette, CPC, CPMA

  5. #5
    St. Cloud, MN
    Default Preventive Visit with Problem Focused visit
    My thoughts are: No matter if any payer or Medicare pays for a preventive visit or not along with a problem focused visit - you must always have the proper documentation for the service(s) rendered.

    I think most payers are allow both a preventive and a problem focused exam, if both are completed and documented. When a patient has additional problems at the time of a Preventive Medicine service it does take more time and Medical Decision Making for the provider.

    Yet, I think it would be difficult in most situations to support a problem focused visit at the level of 99214 along with a Preventive Medicine Visit.

    As you will read in CPT under Preventive Medicine Services the problem focused visit needs to involve significant, additional work: "If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work..."

    The work the provider does (and documents) for the preventive medicine visit is counted towards the preventive medicine service (99381-99397). The ADDITIONAL work the provider completes is counted towards the problem focused E/M visit (99202-99215). If the provider does not document & complete the ADDITIONAL work, a problem focused E/M visit should not be reported according to the CPT instructions, also found under the Preventive Medicine Services.

    Remember with a 99214 problem focused visit you will need a detail history, and Medical decision making of moderate complexity. You already have your exam in the Preventive Medicine visit - even if you do some additional exam depending on the nature of the presenting illness, it would be hard to have an additional detailed exam over and above your provider's typical comprehensive exam for a preventive medicine visit. You only need 2 of the 3Key Components to meet 99214, but this would be a patient with multiple problems that are more than likely not all stable to meet the detailed Hx and the moderate complexity required to submit 99214.

    Most problem focused visits along with a preventive medicine visit are not going to warrant all the additional workup to meet 99214. Most preventive and problem visits completed at the same time will either be 99212 or 99213 for the problem focused visit.

    Cindy Norling, CPC-H, CCS-P
    St. Cloud Local Chapter President

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