# New patient Preventative and problem exam



## cynthiaj54 (Mar 12, 2008)

If a patient comes in to establish with a physician and he performs both preventative and problem exams are they both coded as new patient?
Thanks


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## hpycoder (Mar 12, 2008)

yes, as long as this is indeed the patients first time to be seen by this
physician.  also, keep in mind new patient is one who has never been seen,
or seen within the last 3 years.


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## rthames052006 (Mar 12, 2008)

correct, don't forget to add your 25-modifier.

Roxanne Thames, CPC









cynthiaj54 said:


> If a patient comes in to establish with a physician and he performs both preventative and problem exams are they both coded as new patient?
> Thanks


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## efrohna (Mar 14, 2008)

I don't know if I agree with this one.  Remember a *new* patient visit needs 3 out of 3 components to determine the level.  You cannot double dip on the exam.  Your preventive visit should be coded as a new preventive, but the office visit should be established.  It is easier to carve out the established visit with 2 out of 3 components being the history and medical decision making.  

Both visits should stand alone - without double dipping.  Most payers too, will deny two *New* E/M's on the same day.  

Good luck.
E. Frohna


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## rthames052006 (Mar 14, 2008)

Per CPT: If an abnormality/ies is encountered or a pre existing problem is addressed in the process of performing this preventive 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 service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. 
In my opinion, if CPT meant for an established patient code to be billed only with the new patient preventive example above,the codes starting within the New Patient range starting with 99201 would NOT be referenced as one of the codes applicable.


Roxanne Thames, CPC















efrohna said:


> I don't know if I agree with this one.  Remember a *new* patient visit needs 3 out of 3 components to determine the level.  You cannot double dip on the exam.  Your preventive visit should be coded as a new preventive, but the office visit should be established.  It is easier to carve out the established visit with 2 out of 3 components being the history and medical decision making.
> 
> Both visits should stand alone - without double dipping.  Most payers too, will deny two *New* E/M's on the same day.
> 
> ...


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## efrohna (Mar 17, 2008)

RThames,
I didn't say you can NEVER bill 2 New E/M's on the same day.  I'm only cautioning the double dipping on the exam component.  Both visits should stand alone, if you are going to bill 2 new.  Also, some payers not all, will deny one of them.  
Good luck.
E. Frohna


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## Lisa Bledsoe (Mar 17, 2008)

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.
Lisa


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## rthames052006 (Mar 28, 2008)

efrohna said:


> RThames,
> I didn't say you can NEVER bill 2 New E/M's on the same day.  I'm only cautioning the double dipping on the exam component.  Both visits should stand alone, if you are going to bill 2 new.  Also, some payers not all, will deny one of them.
> Good luck.
> E. Frohna



E. Frohna,

Not a problem at all.... I tried emailing you privately... I wanted to say that I guess I am so used to having to defend myself (with the md's I work for) that I do get defensive, and I wanted to apologize... Sorry................

I think after 11 years with these guys I'm getting in a "burn out" mode... I think it maybe time to find a new coding job with another group.

Have a good weekend.


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## jennifer.cooper (Mar 30, 2008)

Yes you can just append the modifier -25.


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## jcecchini1 (Feb 5, 2009)

*New preventative with new patient problem exam*

How can we find out if both are appropriate?  Our MD's want to bill both new preventative examination and new patient examination?  Is there any where that states "NO" or "YES"?


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## RebeccaWoodward* (Feb 5, 2009)

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.


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## RebeccaWoodward* (Feb 5, 2009)

*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.  


http://health-information.advanceweb.com/Editorial/Content/Editorial.aspx?CC=95357


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## rachlowe (Feb 6, 2009)

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.


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## LLovett (Feb 6, 2009)

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


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## Lisa Bledsoe (Feb 6, 2009)

I agree with Laura.


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## SCanterbury (Feb 9, 2009)

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


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## meganpoelzer (Feb 25, 2009)

*Ins companies pay NP E/M w/ PE*



Lisa Curtis said:


> 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.
> Lisa



Lisa,
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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