Medicare Compliance & Reimbursement

he key is to demonstrate the separate nature of the additional E/M service, says Palmetto.

If you find coding and billing for an encounter that combines an annual well visit (AWV) with a separate health issue challenging, then Part B MAC Palmetto Medicare has a useful tip for you.

Background: The Centers for Medicare & Medicaid Services (CMS) covers an exam for a new Medicare patient called the initial preventative physical exam (IPPE) (G0402), as well as an AWV (G0438-G0439) once a year, but otherwise does not pay for preventive
E/M services. Both the IPPE and AWV have very specific parameters that you must cover when you perform these services, and when patients have additional needs that fall outside of these parameters, physicians might want to address both issues at the same visit, which can lead to a confusing coding scenario.

Palmetto issued a tip to practices on April 21, reminding that although you are permitted to report both the E/M code and the IPPE/AWV, you must ensure that you aren’t double dipping by including documentation from the IPPE or AWV when calculating your E/M code.

“When the physician or qualified NPP provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or AWV, CPT^® codes 99201-99215 may be reported, depending on the clinical appropriateness of the circumstances,” Palmetto says. “Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be submitted for the medically necessary, separately identifiable, E/M service.”

Make Sure to Use Modifier 25

If you want to be sure to collect payment for both the
E/M service and the AWV or IPPE, don’t forget to 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) to your E/M service code.

In the CMS document The ABCs of the AWV, the agency says, “When you provide a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service in addition to the AWV, Medicare may pay for the additional service. Report the CPT^® code with modifier 25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury or to improve the functioning of a malformed body member.”

Don’t forget to bill patients for their portion of the E/M service (copayments, deductibles, etc.) even though they typically won’t owe anything for the AWV or IPPE. “Cost sharing will apply to the E/M service that is furnished during the IPP Exam as the Affordable Care Act only waives the cost sharing requirement for the IPPE and not the E/M service,” said CMS’s Stephanie Frilling during a March 28, 2012 National Provider Call regarding the IPPE and the AWV.

Two Examples Help Guide You

If you aren’t certain when a secondary condition might prompt a separate E/M service along with an AWV, consider the following two examples:

Example 1: “A patient comes in for their AWV and while they are being seen, they tell the doctor about low back pain with pain radiating into their leg,” says Rebecca L. Odell, CPC, CPCO, CPB, CPC-I, billing team leader with Advanced Health Partners, Inc. and AAPC chapter president in New Windsor, NY. “They state the pain started approximately a week ago after gardening and it is happening more and more frequently with occasional numbness in their right foot. The doctor does a complete workup and sends the patient for an MRI or further testing. He wants to see the patient to discuss the results in a week.”

For this visit, you can report both the AWV and an E/M code with modifier 25 appended. “However, the doctor needs to document properly,” Odell says. “To keep the two codes separate, the doctor should write two different notes — one for the AWV and one for the E/M code. The information being used for the E/M code shouldn’t be used in the AWV note. When documenting, it should be treated as if the patient was seen for two separate encounters.”

Example 2: “A condition that could prompt a deeper E/M would be a chronically ill type two diabetic with multiple manifestations that include circulatory issues along with long-term use of insulin,” says Geanetta Agbona CPC, CPC-I, of CGS Billing Service. “In this case, those issues would need to be addressed swiftly. If the physician does provide both services on the same day, it should be well documented and the notes should clearly indicate that two separate services were rendered,” she adds. In these examples, you will report the AWV as well as the additional E/M service. You’ll append modifier 25 to the E/M code.

Resource: To read Palmetto’s April 21 Weekly Tip, visit www.palmettogba.com.