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Preventative and Addtional Complaint

  1. #1
    Location
    Overland Park, KS
    Posts
    1,166
    Default Preventative and Addtional Complaint
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    I have a coding issue that I would like additional opinions on please. Per the CPT guidelines, if the patient presents for a preventative exam and during the course of the exam an abnormality is encountered or a preexisiting issue is addressed and the addtional problem requires addtional work to perform the key components of a problem-oriented E/M service, then you code the preventative code and the code for the addtional office visit with modifier 25 appended.

    My question is this...the guidelines state "problem-oriented E/M service" is this interpreted to mean 99201 or 99212? If the addtional complaint was 99213 or higher, would you code it along with the preventative? I'm thinking that if the patient's addtional complaint is 99214, they would be too sick really for a wellness exam.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Default Can of worms..lol
    You will probably get many different opinions about this but here is mine.

    I see many situations in which a preventive is done along with a 99214.

    Think about it. What does it take to hit a 99214? It is 2 of 3 and since you are doing a preventive service you can pretty much forget about getting credit for exam, how can you separate it out? So you are looking at history and mdm. You need a cc (earache), 4 HPI elements (left ear, 3 days, can't lay on that side, tylenol doesn't help) 2 ROS (runny nose but no fever), 1 PFSH (NKDA), and moderate mdm (OM -new problem 3 points, antibiotic- Rx management).

    Does an ear infection stop you from doing a preventive visit? I wouldn't think so. Does it support a 4? It sure can if they document enough.

    Just my opinion and how I look at it,

    Laura, CPC, CPMA, CEMC

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I appreciate your opinion very much! Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Great example, Laura
    Laura - great sample scenario!

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default
    I agree. How "sick" a patient is doesn't determine the level of service. It's the documentation of the elements of the HPI, PE, and MDM that determine the level.
    Walker Bachman, CPC, CPPM

  6. #6
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Thanks everyone for the guidance.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  7. Default Preventive Medicine and E/M services
    I work for a carrier whose policy states reporting preventive codes with E/M services should not be a common occurance. To justify the services, the rcords must have sufficient documentation regarding the appropriateness of performing both services and documentation that the key components have been met for the E/M service.

    My questions are:
    1. How would I carve out the respiratory exam for the E/M (bronchitis) if the lungs are normally reviewed for a Preventative? Does it matter, as there are no required number of organ systems for the Preventive Exam?
    2. How to determine what is significant versus minor complaint if modifier 25 is used?
    Last edited by cknittle; 02-17-2010 at 09:57 AM.

  8. #8
    Location
    Dover Seacoast New Hampshire
    Posts
    1,971
    Default
    We've typically billed out office visits with preventive services if the HPI and Assessment/Plan meet the documentation guidelines. (exclude exam, for obvious reasons). However, there should be 'significant additional work' performed in order to do this. For example, a follow up of single or multiple stable chronic conditions within the preventive visit doesn't necessarily meet 'significant additional work'. I'd recommend to only bill an additional E&M visit for a significant acute problem or when multiple chronic conditions warrant a great deal of extra work, such as multiple medication changes or additional investigative workup (not routine). We never code an additional E&M based on time; since there is no time criteria for a preventive exam to act as a benchmark.


    Although CMS almost encourages us to bill both visits, (our carrier, NHIC has us adjust the amount of the Pe by the amount of the sick visit, which gives a break to Medicare recipients), other payers are not so generous, and often charge two copayments. As you can imagine, this is not a patient-friendly practice, and although we don't discourage the billing of two codes when clearly warranted, we don't encourage our physicians to bill out both services every time they do a preventive exam.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  9. Default
    Quote Originally Posted by Pam Brooks View Post
    We've typically billed out office visits with preventive services if the HPI and Assessment/Plan meet the documentation guidelines. (exclude exam, for obvious reasons). However, there should be 'significant additional work' performed in order to do this. For example, a follow up of single or multiple stable chronic conditions within the preventive visit doesn't necessarily meet 'significant additional work'. I'd recommend to only bill an additional E&M visit for a significant acute problem or when multiple chronic conditions warrant a great deal of extra work, such as multiple medication changes or additional investigative workup (not routine). We never code an additional E&M based on time; since there is no time criteria for a preventive exam to act as a benchmark.


    Although CMS almost encourages us to bill both visits, (our carrier, NHIC has us adjust the amount of the Pe by the amount of the sick visit, which gives a break to Medicare recipients), other payers are not so generous, and often charge two copayments. As you can imagine, this is not a patient-friendly practice, and although we don't discourage the billing of two codes when clearly warranted, we don't encourage our physicians to bill out both services every time they do a preventive exam.
    Thanks Pam! Anyone else have comments?

  10. #10
    Location
    Kansas City, MO
    Posts
    431
    Default
    I agree with Pam. This should be rare. The documentation should really be "above and beyond" and support that extra time was spent. It almost never does with my docs. I go through their notes and highlight what would support the problem, and not be inclusive of the "well" visit, and usually come up with only a few sentences....definitely not the hx, exam and mdm needed for an ov.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

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