# Preventive with Office Visit



## kbreynolds

When a physician performs a preventive exam and an office visit on the same day, do they have to have two office notes or can they have one note and try to document the preventive separately from the office visit?


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## KLRuhe

I work for several Internal Medicine and Family Practice physicians.  We have some doctors who are very clear and dictate a separate section in the same chart note regarding the preventive portion of the visit.  However, some just dictate the whole visit as they performed it, which sometimes isn't so nicely compartmentalized.  Therefore, I believe as a coder if I am able to sort out the problems from the preventive visit just by reading the note, then both are supported and billable.  I have actually taken a highlighter to a photocopy of a chart note and identified the portions of the visit that were directed at the patient's problems and support the level that I am billing, just to make it clear for the payer.  What is not hightlighted is the preventive portion of the visit, which has no "component" requirements per se.  However, there should be documentation remaining that supports age appropriate history, exam (usually head-to-toe) and risk factor reduction counseling, screening lab orders, etc. 

Kay, CPC, CCS-P


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## rthames052006

kbreynolds said:


> When a physician performs a preventive exam and an office visit on the same day, do they have to have two office notes or can they have one note and try to document the preventive separately from the office visit?



They don't have to have separate notes as long as the documentation for both visits is clear within that dictation/note.  It would be best if they were documented separately but no rule I know of as of yet that says it's a must.


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## blonde01

This subject was brought to our attention at our clinic.  I am an Assistant Manager for an Internal Medicine Practice.  We were just advised that if a patient comes in for a preventative visit and have a problem, the doctor must have the preventative visit on one progress note and the "problem" visit on a different progress.  They can be billed on one claim, though.

Thanks,

Chastity Cecil, CPC


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## rthames052006

blonde01 said:


> This subject was brought to our attention at our clinic.  I am an Assistant Manager for an Internal Medicine Practice.  We were just advised that if a patient comes in for a preventative visit and have a problem, the doctor must have the preventative visit on one progress note and the "problem" visit on a different progress.  They can be billed on one claim, though.
> 
> Thanks,
> 
> Chastity Cecil, CPC



Can I ask who brought this to your attention and is it from an official source.  I am asking because our Compliance dept just spoke on this topic.


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## blonde01

It was emailed to us my our CPO office.  That is what our CPO office asked us to do.....seperate documentation.  The most important thing to remember is that the documentation must support both services.  See below.....



WELLNESS/PREVENTIVE/PHYSICAL AND PROBLEM/SICK VISITS ON THE SAME DAY(The terms WELLNESS, PREVENTIVE and PHYSICAL are used interchangeably throughout this document.)

If the patient comes in for a wellness/preventive/physical visit and has a Pap smear and breast exam this is included in the wellness visit (99391-99395). 
If a patient comes in for a wellness visit and a problem is addressed, both a preventive and problem visit code may be billed. The documentation must support both services. A -25 modifier should be appended to the problem visit.  
There are several concerns when billing both codes.  Some payers will require the patient to pay two co pays (the patient probably won't understand this), some will only pay one of the visit codes (usually the lesser of the two charges). This is all subject to deductible issues and eligibility issues for the service provided. Not all plans cover preventive services. Some payers may want the preventive service charge reduced by the amount of the problem service charge. It is important to verify eligibility prior to preventive services being provided. Ask the payer how they handle a preventive on the same day as a problem visit.  

MEDICARE ONLY:
If the patient comes in for wellness visit and only has a pelvic exam and breast exam performed use HCPCS code G0101.

If the patient has a complete physical including a Pap smear and breast exam this is part of the wellness visit and it can't be billed for separately. Use the appropriate preventive medicine code from range 99391-99395. This will be patient responsibility, as it is a non-covered service.
If the patient is within the first 12 months of Medicare coverage, the service would be covered as an IPPE and should be billed using G0402. An EKG is also separately billable with this service.
If a pap smear is done we can bill Q0091. (This code is just stating that we collected and prepared the Pap to be sent to the lab.) We can bill both the preventive and Q0091 together.

If a patient comes in for a physical and a problem is addressed, both a preventive and problem visit code may be billed. The cost of the problem visit should be subtracted from the cost of the preventive visit when the charges are entered.  A -GY modifier should be appended to the preventive medicine code. The documentation must support both services. If the problem addressed was not significant (i.e., refilling chronic medications, suggesting OTC medication) only the preventive service code should be billed. 

COMMERCIAL INSURANCE/MEDICARE REPLACEMENT:
Verification of benefits is important, not all plans cover preventive services. Ask how they handle a preventive on the same day as a problem visit.  
 If a Pap smear is done we can bill 99000. (This code is just stating that we collected and prepared the pap to be sent to the lab.) We can bill both the preventive and 99000 together.  Some payers may not allow the charge, but that will be handled according to the EOB.

KIDMED/MEDICAID
 If a patient comes in for a physical and a problem is addressed, both a preventive and problem visit code may be billed. The documentation must support both services.  If the problem addressed was not significant (i.e., refilling chronic medications, suggesting OTC medicines) only the preventive service code should be billed.  The only billable problem visit code allowed with a KidMed service is 99212.  Annual preventive visits are also covered for Adult Medicaid.


Thanks,

Chastity Cecil, CPC
Asst. Physician Practice Manager


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## bigredcag

Having gone through a medicare & blue cross audit . No it does not have to be on 2 seperate forms but it does need to be well documented. The pt should have a complaint. 
i wish the docs would do 2 seperate forms or dictated seperatly. but working for a multispecialty group its hard to get that many doc to agree.
good luck


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## dpeterson39

Great question. When working with Providers on the "e/m split" I tell them that it is not necessary to have two separate documents and anyone auditing; be it internally or externally should have the knowledge base to pull out the supporting documentation for both the preventive and other out-patient visit code (that is IF the Provider has it in the note ). A Provider's time and efforts can be delegated more patient driven on other aspects of the clinical practices instead of jumping through the exhausting hoops created in our technical coding world of medicine. If an external auditor denies the split that is where we come in to defend our Providers codes through the appeals process. We too use the highlighting of the separate portions of the notes when appealing yellow for preventive and green for the medical conditions.   

Hope this helps! the Providers sure like it when they hear this


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## poxleitner

Hi all,
I have a similar situation that I am seeking help on....I have been trying to locate documentation from the Medicare website regarding split billing wellness and illness, and really what their official guidelines are.  We have some controversy on the subject within our facility and administration is trying to push a policy on us that I don't feel comfortable following, hence I am searching for documentation basically to prove that they are incorrect in asking us not to split bill medicare patients and in the event they come in for a wellness and an illness is addressed we are to code only an illness visit that day.  Here is what is says word for word....do any of you disagree with this?

In accordance from guidance we have received from the IMA, Brown's Consulting, Noridian Medicare and Karen Newton, Provider Educator for Noridian Medicare we are establishing the following guidelines.




WELLNESS/ILLNESS CODING

MEDICARE:  If a patient is being followed for an ongoing condition ie; hypertension, diabetics or medication refills to treat an ongoing condition, this visit will be coded as an office call.  If patient is receiving a female exam (Q0081-G0101) and meets the 7 out of 11 requirements, this can be billed in addition to the office call (99211-99215 est-99201-99205 new) with appropriate modifiers.

If a patient comes in for a wellness visit and a problem is found this also will be coded as an office call (exam) codes (99211-99215est 99201-99205 new).

Note: Medicare patient will not receive a split bill for wellness and illness (99381-99387 new-99391-99397 est).

If the patient comes in and is not being followed for a medical condition and no problems found then we code as a preventative service exam (99381-99387 new or 99391-99397 est).  At this point the nurse or physician should inform the patient that this visit will be non covered by Medicare guidelines.

Medicare does not consider preventative visit as a covered service, therefore a GY modifier should be used stating we understand it is a statutory exclusion, not a medical necessity issue.  Statutory exclusions do not require an ABN to be signed.

MEDICAID:  If patient is treated for a wellness & an illness, the wellness visit is what should be coded if over 21 years of age.  For patient under 21 years of age, we can split bill as per Medicaid guidelines.  Sports physical can be coded as wellness at the wellness price as per Medicaid guidelines; we have established special charge codes for these. 

COMMERICAL-SP:  For commercial insurance we can bill split visits as described in the CPT book as well as from information from the IMA.  



It is my understanding that when you are billing a medicare patient for an illness and a wellness on the same day that you have to deduct your illness charge from your wellness charge example:
99397 197.00
99213  63.00
total billed to patient would then be:
99213-25 for $63.00
99397      for $134.00
IS this correct and where on the medicare website can I find this?
Also I have a note that is similar...
here are my findings within it...
the patient was clearly in for a wellness exam, during this exam the Dr. performed a pap/pelvic, however he did not meet MCR guidelines on his pelvic exam with the criteria of 7 of 11 elements therefore I don't feel I can appropriately report the G0101 code, also the Dr. performs a joint injection to the shoulder (20610), if I try and carve out for the shoulder pain I would get a 99212, but he performed an injection for the shoulder pain therefore I was only going to code the 20610.....heres my dilemma, does the shoulder injection need to be reduced from the wellness exam?
here are my examples of prices and scenarios but not sure which one is correct and need to find MCR documentation to support my decision:
99397 reg price 197.00
G0101 reg price 35.00
Q0091 reg price 40.00
20610 reg price 70.00

should I go with:
20610 for 70.00
Q0091 for 40.00 (deducted from 99397 price)
99397-25 for 157.00
(G0101 not codeable due to lack of documentation therefore not deducted from the 99397)

OR:
20610 for 70.00 (deducted from the 99397 price)
Qoo91 for 40.00 ( deducted from the 99397 price)
99397-25 for 87.00

Thanks for all your help and if any of you have direct links to the Medicare website that explains coding regulations that would be great, also your input on the policy above would also be appreciated!
Thanks again
Ang, CPC


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## majors76

*Dermatology Wellness Visit*

Is it possible to code a preventive visit and an office visit for a dermatologist? I have received conflicting responses to this question.


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