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Thread: New patient Preventative and problem exam

  1. #11
    Join Date
    Apr 2007
    North Carolina


    AAPC: Back to School
    I think this will become carrier specific. Copied from 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.

  2. #12
    Join Date
    Apr 2007
    North Carolina


    Q: What is the proper way to code for a new preventative visit and a new sick visit on the same date of service? Some say you cannot bill a new preventative and a new sick evaluation and management (E/M) code on the same day due to the overlap of history and exam. Some say you can and others say to bill the preventative as new and the sick as established, which is what Medicaid requires. Our office is divided three ways on this issue. Any supporting documentation would be greatly appreciated. Thank you.

    A: Per CPT guidelines, if an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine E/M 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. The E/M code report problem-oriented service should be based on the additional work performed by the physician. Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

    If a physician encounters an insignificant or trivial problem/abnormality in the process of performing the preventive medicine E/M service and it does not require additional work and the performance of the key components of a problem-oriented E/M service, then this should not be reported separately.

    Medicare covers initial preventive physical examination (IPPE) effective Jan. 1, 2005. This "Welcome to Medicare benefit" must occur within the first 6 months (now 12 months) that a Medicare beneficiary elects to participate in Medicare Part B. The service is reported with G0344. Medicare also allows reporting a separate E/M code (99201-99215) when a separately identifiable service is provided. Some of the components of a medically necessary E/M service, for example, a portion of the history and physical (H&P) examination, may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary E/M service.

    Some third-party payers may not follow CPT guidelines. Check with third-party payer reporting and reimbursement guidelines in your area when reporting both a preventive and a problem-oriented E/M service on the same day.


  3. #13
    Join Date
    Apr 2007
    Stuart, FL


    We are often reimbursed for two new patient visits billed on the same date. I don' t see how it would be appropriate to bill a new pt prevent and and established patient sick. Because there are no guidelines or requirements for what is to be included in the exam portion of a prevent visit we always carve out the portion of the exam related to the complaint or illness to figure a new pt visit. Hope this helps.

    Rachael Milley, CEMC, CPMA, CPC, PCS
    Holy Cross Hospital
    Coding Compliance Manager

  4. #14
    Join Date
    Apr 2007


    I think CPT is contradicting itself.

    The definition of a new patient clearly states

    "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."

    Once you have provided a service that is face to face and reported with a specific CPT code, they are an established patient.

    I think it should be new preventive and established problem.

    Laura, CPC

  5. #15
    Join Date
    Apr 2007
    Greeley, Colorado


    I agree with Laura.
    Lisa Bledsoe, CPC, CPMA

  6. #16
    Join Date
    Apr 2007
    Jacksonville, FL River City Chapter


    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)."

    This is based on the logic that the new vs. established decision is made each time a patient "presents" to the office. They may receive multiple services during the initial "presentation," but if they were provided back-to-back during this initial "presentation," we do not change the label after the first service. The label assigned when they walk in stays with this patient until they leave the office.

    Seth Canterbury, CPC, ACS-EM

  7. #17

    Default Ins companies pay NP E/M w/ PE

    Quote Originally Posted by Lisa Curtis View Post
    Just want to point out that no payer will reimburse for two new patient visits on the same date; so Efrohna is correct in the suggestion to code the new patient preventive medicine and the established problem oriented visit.
    Our practice bills NP preventive visits with a NP E/M on the same date. In our experiences, most insurance companies will pay half of the allowed amount, if not all (including BCBS, Cigna, Aetna, and UHC).

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