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Preventive and Add'l E/M code

  1. Post Preventive and Add'l E/M code
    Medical Coding Books
    I work for an Internal Medicine office. We've recently been experiencing several insurance companies denying or bundling the CPT codes for a preventive visit when we bill with an an additional E/M code for a problem visit. We are using the appropriate modifier and diagnosis. Has anyone else had this problem lately?

  2. #2
    What modifier are you using? Did you also call the payors to check with them why they are denying the services?

    Nidhi M.

  3. Default
    E/M visit appended with 25 modifier and diagnosis other than V70.0, say any other routiene complaint but required urgent attendance that day such as asthma, arthritis as per medical record.
    This is followed by preventive medicine section codes with V70.0 or V20.2 as Dx depending on whether adult or child respectively and other vaccination codes as may be required.
    BCBS does not cover E/M visit and preventive medicine for the same DOS, these days. We need to supply the correct Dxs to prove medical necessity perhaps.


  4. Default

    I have also experienced the same situation. My question to you is which insurances or insurance's plans have they bundled these services? This is something that we should keep track of as it impacts revenue and the way the physician would need to practice. LM is correct that some insurances now bundle E/M and Preventative services and will reimburse the cpt code with the least reimbursement. So presumably after bundling your services, they will reimburse the cpt code with the least reimbursement. I would call your insurance company and ask what their policy is for bundling E/M visits with Preventative visits and appeal the claim. You will have to provide the medical record and demonstrate that these were 2 separate encounters with the patient.

  5. Default E/M visit w preventative visit
    Hi there, I also work in an internal medicine office and this is what I have found helpful.

    If all documentation is in chart to warrant e/m visit:
    When inital billing, Code line #1 with E/M visit, Dx that pertains to E/M visit only* modifier 25 appended

    Code line#2 Preventative visit with correct V code

    Because some payers may reject I will then resubmit ov notes w rejected e/m visit for manual reconsideration. This usually works. Let me know how it goes

    Good luck
    Last edited by gbrown; 08-16-2009 at 07:37 PM. Reason: sorry, typo

  6. Default
    We do apply the 25 modifier to the E/M code and bill with the problem visit dx. Our experience has been with United Healthcare and Aetna thus far bundling the services stating it is not separately reimbursed. I have also read in a Humana newsletter that they will start doing this as well starting October of this year.

    Thank you all for your suggestions. I will start with contacting the insurance companies regarding their policies.

  7. #7
    Hi everyone,

    Our gastro group just joined with an internal medicine group, so I am new to billing for PCP's. I hope you will be able to help me with the following questions:

    When a patient is being seen for a preventative medicine visit, such as 99396, we bill with a dx of V70.0. But many of the physicians are also submitting billing for an additional E/M, such as 99213 with a dx of 401.1 and 272.4. (and we are attaching a -25 modifier to the 99213)

    So, my questions

    Is this how you are coding in these situations?

    How common is it to bill a preventative medicine visit and an additional E/M visit on the same date of service? Does this happen rarely, or all the time?

    Is this a red flag for an audit?

    Do you discourage your physicians for billing for both services on the same date of service? (i.e. - are the physicians encouraged to schedule a separate E/M visit on a different day to address the problem/illness?)

    And since the original post is a few years old, which insurance companies are bundling the E/M and preventative medicine visit together?

    Also, is it common for the internal medicine physician to do an EKG as part of the preventative medicine visit, in older patients? (Billed with a separate code from the 99396)

    Thank you so much!
    Last edited by Colliemom; 01-17-2014 at 01:09 PM.

  8. #8

  9. #9
    Columbia, MO
    it is unfortunately all too common a practice. However with the introduction of the affordable care act you must make certain that the ov is for a patient requested complaint. Also this can no longer be done as of Oct 1 2014 due to the way the ICD-10 CM codes are worded for the general preventive dx. If you have not looked at the ICD-10 CM codes then you really need to do this as soon as you can.

    Debra A. Mitchell, MSPH, CPC-H

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