Eli's Rehab Report

Question: We know that Medicare does not pay for well visits (preventive medicine), but what if the physiatrist finds a problem during a physical? Can we bill using the ICD-9 for the problem, or as a well visit? Is there any way to bill pro rata based on how much time was spent on the visit and evaluating the problem?

Maine Subscriber

Answer: CPT dictates that if a problem is found during a preventive medicine visit, and if it is significant enough to require additional work to perform the key components of a problem-oriented E/M service, the appropriate preventive medicine code (99381-99397) should be billed with 99201-99215 (new or established patient). Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to 99201-99215 to demonstrate that a significant, separately identifiable E/M service was performed.

However, CPT also states that an insignificant problem found during a preventive medicine visit should not be coded separately. For instance, if the physiatrist performs periodic physicals for high school athletes, those should be coded using 99394 (established patient; adolescent [age 12 through 17 years]). If the doctor finds that one of the athletes is suffering from athletes foot and prescribes an over-the-counter medication, that would not be separately identifiable. The athletes foot condition would not require a separate history of present illness, and therefore would not require separate billing.

The preventive medicine codes are noncovered services by Medicare, so those patients would be responsible for paying their portion. Medicare allows you to carve out the charges for the part of the visit that addresses the problem, and you can bill separately for those. Be aware that your documentation for such claims would have to prove that all aspects of the sick visit E/M codes were performed.