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Preventative exam w/office visit E&M

  1. Default Preventative exam w/office visit E&M
    Medical Coding Books
    Our pt came in for a pap/pelvic and also had a UTI with symptoms. The pt was new to the provider. Should we bill the preventative exam and the office visit with the new pt codes or should we bill one of them with the established codes?

  2. Default E&M with CPX
    Hi Tammy, It is appropriate to bill the E&M with a new pt code and modifier 25appended to the E&M visit and then bill the established patient physical/Preventative exam. Although per CPT it is appropriate to bill both services good luck getting both services paid for without an appeal process

  3. #3
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    Greeley, Colorado
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    I do it the other way around; New patient 99381-99387 and establishded 99212-99215 (mod -25). The initial reason for the visit is the preventive exam, the problem-oriented is discovered during that visit. CPT does indicate that you can code both new, but in my experience insurance will not pay for two new codes on the same day even with modifier -25.
    Lisa Bledsoe, CPC, CPMA

  4. #4
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    I agree with Lisa, but you will find this is a hot topic that splits coders down the middle!

    Laura, CPC, CEMC

  5. #5
    Location
    North Carolina
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    So true Laura......

    Although CPT Assistant does support both (new), I would check with your individual carriers. I have many that do honor this guideline.

    Per CPT Assistant (Oct 1, 2006)

    Evaluation and Management

    Question: If a preventive medicine service (99381-99397) and an office or other outpatient service (99201-99215) are each provided during the same patient encounter to a new patient, is it appropriate to report each evaluation and management (E/M) service as a new patient visit? Or is it appropriate to report the preventive medicine service as a new patient and the acute visit (ie, office or other outpatient service, 99201-99215) as an established patient?

    AMA Comment: It is important to first take careful note of the New and Established Patient instructions provided in the E/M services guidelines of CPT 2006 (page 1). Specifically, the guidelines state:

    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).

  6. Default
    That is correct, however, most edit/claimscrubbers worth their weight wont allow this 2 new visits ,same doc, same day, scenario to even get past your billing system and if so you will certainly jump through hoops with most carriers to get both New paid. You can and should bill an E&M and CPX on same day if documentation supports both. Also, it is correct to bill your E&M service BEFORE your preventative service per CPT 2009 GUIDELINES. UNDER THE PREVENTATIVE MEDICINE SERVICES SECTION, THE GUIDELINES CLEARLY STATE THAT " If an abnormality/ies or a preexisiting problem is addressed IN THE PROCESS OF performing this preventative 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 preventative medicine service. The appropriate preventative medicine service is ADDITIONALLY reported." ,
    ex: 992XX - 25, 993XX

    Karen Urbas, CCS, CCS-P, CPC

  7. #7
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    I don't take the word additionally to mean secondary myself.

    I would order them in RVU order, which would be your new preventive 1st and your established problem 2nd.

    Laura, CPC, CEMC

  8. #8
    Location
    North Carolina
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    3,126
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    Personally speaking, I don't jump through hoops. Many of my carriers allow for both if the guidelines are met.

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