# Preventive plus sick



## sbicknell (Jan 29, 2009)

I am looking for guideline in writing and have failed to find anything on the internet or CMS.  The issue is when a new patient presents for initial preventive exam and an additional condition is evaluated and treated with additional separate work involved.  

Is this coded:  99383 and established E&M 99212-99215 OR is this coded 99385 with new E&M 99201-99205? Understand mod -25 is used

thanks


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## dmaec (Jan 29, 2009)

it would be coded as a "new patient preventive" (99381-99385) and an "established patient E/M" (99211-99215).
Once the patient is "seen".... for the preventive, they are no longer "new"... you can't have two new patient visit's, same day, same doc/specialty...

and yes, you're correct - you'd need the modifier .25 on the E/M


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## scronkhite (Jan 29, 2009)

I guess I am a little confused, I have also come across this and my supervisor has stated the opposite.  He said that the patient is new so yes you would code it as a new preventative and a new office visit.  Do you have or can you tell me where I can get this in writing?

Thanks, Sue


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## dmaec (Jan 29, 2009)

certainly - the guidelines in the CPT Manual states, (page 1) --
"soley for the purposes of distinguishing between *new* and *established* patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 
A new patient is one who has not received any professional services from the physician or another physican of the same specialty who belongs to the same group practice, within the past three years. in your case they have, because they just seen your physician for the physical (granted, the sick was rolled into the same office visit - I'm sure they didn't leave the office and come back in)

An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. This is what your patient is at this point, established - because they've already had a physical by this provider (which will be a new patient charge assuming this is the first time your provider/group has seen the patient) and then they went on to provide "another" separately reportable E/M visit... second visit, same doc/group/practice - no longer new..


so you see, once your physician see's the patient for the FIRST time (let's say the appointment was set up as a physical/preventive service),.. pt comes in and add's the "oh yeah, and I'm sick, or I hurt here or whatever" -which is then ABOVE and BEYOND the physical ... the provider can charge an E/M for that service as well (it'll need a .25 modifier on the E/M) However - the patient CANNOT be "new" twice... you see?  So the second charge is an established patient charge.  Now IF you patient see's another provider NOT of the same specialty - then they can charge a NEW patient charge that day too... BUT not your "one" doc that sees them for both the preventive and sick visit, same time (or even if it was two different docs, same specialty, seen for physical  then sick visit  - second doc does not get "new" patient.


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## RebeccaWoodward* (Jan 29, 2009)

I just wanted to add one thing...

Is this patient coming in for their IPPE?  If so...please refer to 30.6.1.1 G

G*. Reporting a Medically Necessary E/M Service at the Same IPPE Visit*
When the physician or qualified NPP provides a medically necessary E/M service in addition to the IPPE, CPT codes 99201 – 99215 may be used depending on the clinical appropriateness of the circumstances. CPT Modifier –25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE code reported (G0344 or G0402, whichever applies based on the date the IPPE is performed). NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) 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.

30.6.2 Also provides additional information

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Last but not least.....

http://www.cms.hhs.gov/manuals/downloads/clm104c18.pdf


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## scronkhite (Jan 29, 2009)

I just read the 2 sites that you reccommended and neither one says that you can not bill 2 new patient codes.


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## dmaec (Jan 29, 2009)

do you get the part in the CPT book though?  about what a new patient is exactly?  If the patient has already been seen by that provider AS A NEW PATIENT, they are no longer "new"... (or if they're seen by another provider same specialty/group)... If they're new ONCE to the provider (or another same specialty/group) they can't be new again UNLESS they haven't been seen in 3 years. 

it doesn't get much clearer than that..


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## RebeccaWoodward* (Jan 29, 2009)

My thread was really addressing the first post; however, I do have some information you might find helpful.

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 (12 months now) 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

Now...My CPT book  (CPT 2009 Professional Edition) has the area I *underlined* on page 29 (under the Preventive Medicine Sevices)

I can tell you that some of our carriers require an established E/M code when billing in conjunction with a PE.  I would refer to your carriers for clarification.


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## dmaec (Jan 29, 2009)

this link has a "decision" tree on it - if you use it, you'll see, your second service will be an established patient charge:
http://medgenmed.medscape.com/viewarticle/462015_print

great post Rebecca!  And page 29 of the CPT book too!   It's quite clear all when we can code new vrs est.


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## scronkhite (Jan 29, 2009)

I clearly understand the difference between new and established, however I was trying to see if anyone had information on where besides the cpt book that I could locate in writing that you can not bill a new pt preventive and a new patient office visit at the initial visit.


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## dmaec (Jan 29, 2009)

well, good luck with that - let me know how it turns out... 
*shrugs* it just doesn't get any clearer to me, and I don't know how to explain any other way. 
but if you know the difference between new and established - and guidelines that have to be followed,...then you should be able to see that you can't bill a patient two new patient services in the same day for the same provider or same specialty/group. *shrugs*


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## sbicknell (Jan 29, 2009)

The statement below seems to support that a 99385 and 99201 can be coded for the same visit (preventive with sick).  The statement is 99201-99215.  Doesnt that mean 99385 + 99201 or 99395 + 99212 with new/new or est/est?

Anybody have a clear statement on this in writing?

Per CPT guidelines, ..................then the appropriate office/outpatient code 99201-99215 should also be reported.


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## RebeccaWoodward* (Jan 29, 2009)

I do agree that the guidelines state you can bill new or established E/M codes with a PE but I really think this can become carrier specific.

*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.

As you can see...UHC is one of our carriers that do allow this.


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## dmaec (Jan 29, 2009)

key word is *appropriate*
per guidelines, you can't be new if you've already been seen by that provider or another of same specialty/group (and you're coding out the preventive service as a NEW patient) - then you've Established that patient by coding the initial service as new... so that being said, the *appropriate *code to use on the E/M is esablished.

(k, I almost didn't post again - but now I'm done cuz I just can't make it any clearer) it seems quite obvious to me and I apologize at my inability to explain any further)


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## SCanterbury (Jan 30, 2009)

Donna, 

The theory that performing the preventive medicine service causes the patient to become established in-between the preventive service and the problem-based service is interesting, but incorrect. Note that the notes preceding the Preventive Medicine codes indicate that a problem-based encounter performed with a preventive medicine service is coded from *99201*-99215. 

The fact that the new patient (99201-99205) codes were included as possible codes used to describe the problem- based visit shows that your theory about the patient becoming established in-between the two services is not valid. If that were true, the new patient codes would never be used with a preventive medicine service.

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)." _

Seth Canterbury, CPC, ACS-EM


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## rebecca lopez (Jan 30, 2009)

*preventive and sick same day*

refer to the CPT book under the preventive codes read the guidelines. It gives the information there.


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## RebeccaWoodward* (Feb 1, 2009)

Sbicknell...

Do you feel better about coding these now?


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## rebecca lopez (Feb 2, 2009)

*new prevenitve and new sick*

We came across this issue before. You could code both new, but if you literally take the guidelines you should code New for the preventive if patient made an appointment for a preventive then the MD has documentation to support the sick visit. 
Some of our physicians feel they are new to them when doing a the preventive and then is considered established when they perform the sick.
Hope this helps. I have instructed staff to review the appointment and code accordingly. The patient will be responsible with two co-pays.


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## btadlock1 (Dec 9, 2009)

*new PE & sick same day*

I can tell you that from a commercial follow-up perspective I see denials in 2 situations often:
1. Both PE & sick billed as new
2. sick billed as new and PE billed as established

Either way produces the same result - the PE visit pays, and the sick visit denies as "new pt code billed for an established pt". 

My best guess as to why this happens is that since the sick visit is "additional work" beyond the PE, the PE is considered the "primary" procedure of the 2, and processes "first". If you bill it as established, then they'll pay it as established, but when they get to the sick visit, they've already decided that the patient is established, so they won't pay it. 
If the PE was billed as new, then they'll pay it, but they definitely won't pay more than one new pt code for the same practice/specialty (unless it's been over 3 yrs, of course). 

So the only situation that seems to work is
New PE + Established Sick E/M (w/25 mod) = no denial. 

It's an easy way to justify paying less overall for both procedures, and to deny one of them whenever possible. It would be nice if the CPT book were a little more specific on the issue though.


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## RebeccaWoodward* (Dec 10, 2009)

I agree that billing for a new wellness/new problem oriented visit poses some hurdles for reimbursement but if the guidelines are met, they are _billable_.  Depending on the carrier..._payment_, for both (new), may be another story.  CPT Assistant does provide guidance on this and if an appeal was in order, this could be referenced.

Excerpt from 10-2006

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 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.

An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

*Therefore, 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).


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## kumeena (Dec 10, 2009)

If it is same D.O.S I would code both visits (preventive and Sick) either new or established. It can not be one new visit and one established.without any lab work (basic) or any work-up how is it possible (established visit).

Awaiting for feedback from others


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