Eli's Rehab Report

Question: At a seminar I was told that if a physician tells a patient to come in once a year for a follow-up, the visit is not considered a preventive visit. But, if they come in once a year for a routine exam it is considered preventive medicine. How do I code for an annual follow-up exam for a patient who is in remission for lupus and returns each year for a review of symptoms?

California Subscriber

Answer: Differentiating between preventive and follow-up exams can be tricky, and the cost difference is substantial. For example, a 99397 (established patient, periodic preventive-medicine reevaluation and management) normally pays about $118, while a 99213 (established patient, office or other outpatient evaluation and management [E/M] visit) pays about $47, depending on the Medicare carrier. Its important, however, to keep in mind that although Medicare has established relative value units (RVUs) for preventive medicine, Medicare does not cover preventive-care visits as a benefit (the RVUs most likely were established for Medicare managed care programs).

The key to distinguishing between the two lies in the wording of the chart documentation. The appropriate way to bill for your physician recommended follow-up visit is with an established patient CPT code (99211-99215) and the appropriate diagnosis for the lupus (710.0). The documentation must clearly indicate that the intent of the visit was to follow-up on the chronic illness and not to perform a routine exam. We recommend that the documentation begin with, The patient presents today for re-evaluation of her lupus. This statement clearly establishes a chief complaint, indicating that it is a problem visit (versus a preventive medicine visit), which is a reimbursable visit under the Medicare program.

Billers should note that CPT 2000 dictates how preventive-medicine visits should be documented if abnormalities or pre-existing conditions also are addressed during the exam: If the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, the appropriate office/outpatient code (99201-99215) should also be reported. Coders would then indicate the preventive-medicine code (99381-99429) and the appropriate office/outpatient code with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached.

If a visit is truly preventive and no problems or complaints are identified, the physician should bill the patient (and obtain a waiver of liability) but should not bill Medicare.