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Preventive, office visit, and procedure done on same DOS

  1. #1
    Question Preventive, office visit, and procedure done on same DOS
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    I posted t his under the General Discussion board for coding but haven't been very successful at getting a response. So here I am posting it in the E/M discussion board to see if anyone would know this and give me feedback>>>I would greatly appreciate it! Thanksss!


    I need clarification and confirmation on this issue. We have a claim that was billed on the same DOS codes:

    99396- Preventive visit
    99213 with mod 25- E/M visit
    11302- Shave skin lesion

    We are getting a deny edit on the 99396 as being bundled in to 11302.

    My rationale was that modifier 25 will need to also be appended on the 99396 also to make this a distinguish service from procedure 11302. Same concept applied to the 99213 that's why the provider billed it with modifier 25 to eliminate this coding issue.

    Am I correct?

    Thanks in advance for the help!


  2. #2
    Default question of my own
    Sorry, I can't answer your question but I do have one of my own.

    Cardiologist sees a patient with no cardiology symptoms but a family history of cardiology related disease who was concerned about their chances of having or developing the same disease/problem. What diagnosis would be best to use? Is the family history codes sufficiant to payers for reimbursement?


  3. #3
    I would use a screening code for cardiovascular disease and perhaps also code the family history code of cardiovascular disease as well.

    Now can someone answer my question too? lols =)

  4. #4
    Smile Preventative visit & OV same dos
    I work in an internal medicine practice and my physicians always like to bill this as well. The Preventative Visit must meet all guidelines for billing as well as the OV must be able to stand alone and meet separate guidelines. Make sure that both visits pass auditing and you do the carve-out correctly.

    We bill this way:
    99396 (V70.0)
    99213-25 (dx codes)

    I always advise my physicians to complete separate notes to make sure that they meet coding guidelines without double dipping into the exams.

  5. #5
    Thank you Coding4fun for replying! =D

    So the carrier that you submit these claims to don't require the modifier 25 on the preventive? But confirm this, strictly from a coding perspective, a modifier 25 would be needed to be appended on the preventive to show that it's a distinct service from the performing the procedure, correct? Because per CMS a modifier 25 needs to be appended on an E/M visit (the preventive is an E/M visit as well) when a minor procedure with a global day of 000 or 010 is billed too.


  6. Default
    Many carriers will deny the preventive and E/M on the same day.

    If the patient has other might want to schedule another visit

    As far a procedure that have a global period on them it would best to have the patient come back on another visit if you want to be paid

    Unfortunately the government has taken a big stand to make medical decisions on patient care

    Good Luck

  7. #7
    Thank you CONSULTA-A-CODER for replying! =) I appreciate it.

    However, since we are a carrier and we can't tell providers how to bill, I must go off of what codes were billed and review the claim according to the codes..and at the same time try to ensure that all coding scenarios, however it's billed must be correct coding. I understand that if providers really want to avoid all these coding issues, they should reschedule the patient for another visit. However, probably due to physician-patient relationship the provider may not want to put this restriction on the patient and decides to do as the member ask on this particular visit. Because we can't fault the provider for providing the best possible care to our patients/members, we would want to allow a situation like the one I've been questioning so far, paid. However, IF providers do choose to perform the services in this manner, they must bill correctly to avoid any bundling issue as well.

    Any have any thoughts on this as well or comment on my coding question in my previous posts? Thanks!

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