EM Coding Alert

Question: I’m trying to understand what we can bill to Medicare during a patient’s preventive visit. Our physician wants to report these codes:

• G0402 with diagnosis V70.0
• 99214 with modifier 24
• 82947
• 81002
• 99173
• 94010

Additional diagnoses 788.41, 250.00, 272.4, and 401.9.

Are all these codes permissible?

Alabama Subscriber

Answer: Some of the codes your physician listed are permitted, but others are not. Share this information with him to help explain the coding:

• G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) with diagnosis V70.0 (Routine general medical examination at a health care facility): These codes are billable. Remember you can only report G0402 one time during the first year the patient is on Medicare. The next year, report G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit). For subsequent years, report G0439 (Annual wellness visit, includes a personalized prevention plan of service [PPS], subsequent visit).
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period): The Level 4 office visit code might be billable if you have documentation to support the key E/M components that is separate from the IPPE documentation. Instead of modifier 24, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Connect one or more of the additional diagnoses to this code to indicate the reason for the significant and separately identifiable E/M service.
• 82947 (Glucose; quantitative, blood [except reagent strip]): This service is sometimes done as a screening. However, the additional diagnoses below indicate that the patient already has a diagnosis of diabetes, among other things. That means the test is being used for diagnostic purposes instead of as a screening, so it should also be billable with the appropriate additional diagnosis(es) attached.
• 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy): This diagnostic test is billable because of the associated diagnosis noted below, 788.41 (Urinary frequency).
• 99173 (Screening test of visual acuity, quantitative, bilateral): Vision acuity screening is included in the IPPE, so it is not separately billable in this scenario. Vision screenings are not part of a patient’s annual wellness visit (AWV) codes G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit) and G0439 (… includes a personalized prevention plan of service [PPS], subsequent visit). That might explain why your physician thinks he can bill the vision screening with an IPPE.
• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation): Your notes and the listed diagnoses don’t make it clear why spirometry was performed. Verify that a diagnosis in the patient’s chart supports administering the test. If so, append that diagnosis to 94010 to support the medical necessity of the service.
• Additional diagnoses 788.41, 250.00 (Diabetes mellitus without mention of complication; type ii or unspecified type, not stated as uncontrolled), 272.4 (Other and unspecified hyperlipidemia), and 401.9 (Unspecified essential hypertension): Each of these diagnoses is reportable, assuming the physician’s notes document the conditions.