Ob-Gyn Coding Alert

Discover the best way to use modifier 25

Think you can't receive reimbursement for annual physical examinations and other preventive screenings? Think again.

Medicare may not cover many preventive exams (CPT codes 99381-99397), but you can still bill the patient directly for them. And if you perform the preventive screenings alongside Medicare-covered services such as an evaluation and management service, you can bill for both. Experts offer the following tips:

Tip 1: Remove Reluctance From the Equation

Overcome physicians- reluctance to bill the patient for screenings. -Old school- doctors are reluctant to bill the patient, but -I keep telling them they are doing the work and they need to be reimbursed,- says Lisa Center, CPC, coder with Via Christi Health Center in Wichita, Kan.

Tip 2: Use the 50 Percent Rule

Don't bill a problem-focused E/M when the physician actually performs a preventive visit. Use the -50 percent rule,- says Rhonda Gudell, a coder with Aurora Health Care in Green Bay, Wis. If more than 50 percent of the visit was spent on preventive or related services, then bill a preventive visit. Don't bill an E/M visit just because the physician examined some long-standing problems or refilled some prescriptions.

-Educate the providers that it is fraudulent to bill an office visit if the appointment is a preventive exam,- says Kimberly Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis. -Medicare does do random auditing in order to see if providers are billing what should be a preventive as an office visit.-

Tip 3: Be Forthcoming With Patient

Let the patient know up front that Medicare won't pay for all of a preventive visit, and that it's an elective service, says Linda Herrera, MRA analyst with Humana in Kansas City, Mo. Tell her approximately how much her share of the cost will be so there are no surprises.

Sign your name: Ask the patient to sign a form that says, -I am scheduled today to have an annual physical exam. I understand that if my insurance does not pay for this service I am responsible for payment,- says  Christine DuBois, CPC, coding and compliance coordinator for Western Mass Physician Associates in Holyoke, Mass.

Tip 4: Remember Modifier 25

When your physician performs a preventive visit on the same day as a problem-focused E/M, use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). If a patient comes in for a preventive screening visit but turns out to have a problem that requires a separate history and/or physical exam and medical decision-making, you can bill Medicare or other payers for that E/M service.

Warning: But you should only bill a separate E/M service when the patient had a preventive service and the physician spent a significant amount of time dealing with a problem, Center says.

You can bill the patient for the cost of the preventive service, minus what Medicare pays for the E/M. Make sure to charge your patient the copay for the E/M service. Modifier 25 on the problem E/M service lets your own system, as well as the carrier-s, know that there was another service, Gudell says.

Tip 5: Keep an Ear Out for Patient Request

You don't have to bill Medicare for a preventive screening unless the patient requests it, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

If you do bill Medicare at the patient's request, add modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to make it clear you know Medicare won't pay.

Tip 6: Use Caution When Carving Out

-Carve out- covered screenings from preventive visits. If a patient comes in for a preventive screening and has a pelvic exam, breast exam and pap smear, you should bill Medicare for those services, Gudell says. Then bill the patient for your preventive visit fee minus what Medicare paid for those screenings.

Some practices may use modifier 52 (Reduced services) for the preventive visit code along with the Medicare-covered screening codes such as G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the pelvic and breast exam and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the pap smear.