Practice Management Alert

Tip: You’ll need a modifier to explain the clinical scenario.

If your providers see patients for preventive services, you no doubt face this scenario: The patient schedules an annual wellness exam, but while the provider is in the room with the patient she explains she is also having a problem. Many doctors won’t turn the patient away and tell her to come back another time for the problem-oriented care, which leaves your coders with a complicated situation. 

To get your providers the payment they deserve, your coders need to know the pitfalls to avoid when report preventive and problem-oriented services for the same encounter. Read on to ensure your practice isn’t leaving money on the table or encouraging claims denials. 

Ensure There is a Separately Reportable Service

According to CPT®, you can bill a sick visit in addition to a previously scheduled preventive medicine service if the presenting problem “is significant enough to require additional work to perform the key components of a problem-oriented E/M service.”

No double dipping: You must be vigilant about checking your documentation, as “you cannot use any part of the documentation for the preventive exam to determine the level of service for the E/M code,” Smith says.

Tip: Ask yourself, “can I find enough carved-out history, exam and medical decision-making to support an E/M service that is not part of the preventive care?” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

To maximize payment potential, make sure your providers keep notes on the two visits separate. One effective way of doing this is to first draw a line at the bottom of the physical-exam sheet. Then document the history, exam, and medical-decision making relevant to the illness below this line, or turn the preventive medicine template over and document the separate and distinct E/M visit.

Tip: Be sure the well visit and its supporting documentation are easily distinguished from the sick visit and its supporting documentation. Also, make sure you have reported thorough and accurate ICD-9 coding wherever possible to strengthen your claim.

Code the Preventive Portion First

Preventive services are health care services started early to prevent illness or detect illness at an early stage. Some examples include annual exams, Pap tests, flu shots, and screening mammograms.

For the preventive service, you will report a code from either the 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient ...) range or the 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient ...) range depending on whether the patient is new or established. 

“Most payers cover at least one preventive medicine visit annually,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Even Medicare is moving in that direction with the Initial Preventive Physical Examination (IPPE) and annual wellness visits.” 

Next, Assign a Problem-Oriented Code

For the sick portion of the encounter, you will report a code from either the new patient range (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or the established patient range (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), depending on the patient’s status with your practice.

As with any E/M service, the severity of the diagnosis, intensity of medical decision-making and time spent on counseling and coordination of care determine correct coding. Because differentiating the office visit exam from the preventive medicine services visit exam can be problematic, documentation must rest with the history of the present illness and the medical decision-making connected with that illness; or with time-based coding, when counseling/coordinating care constitute more than 50 percent of the face-to-face visit in the outpatient setting. 

Don’t Forget the Modifier

To let the payer know that the problem-oriented service was separately identifiable, and thus separately payable, you need to attach a modifier to the E/M code (99212-99215 or 99201-99205). You will use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Beware: Be sure you attach modifier 25 to the problem-oriented code and not the preventive medicine code. 

Remember: If the problem uncovered during a well visit does not meet the significant and separately identifiable criteria necessary to append modifier 25, you can bill only the preventive service.

Learn By Example

Suppose a six-year-old patient presents for a wellness visit, but the patient’s mother is concerned that the child also has been complaining about ear pain after swimming lessons. The pediatrician examines the patient’s ear and diagnoses her with swimmer’s ear. He prescribes ear drops to treat the otitis externa.

In this case, the patient presented for a physical but the doctor discovered a significant problem that was separately evaluated during the visit. You’ll report the preventive medicine code (for instance, 99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures, established patient; late childhood [age 5 through 11 years]) with the diagnosis code V20.2 (Routine infant or child health check). This requires that all of the elements of the preventive visit are met, even though the child is ill.

In addition, you’ll report the appropriate E/M code (such as 99212-25) linked to 380.12 (Acute swimmer’s ear).