Primary Care Coding Alert

Presented by Susan Pincus, CPC, CHC

The following supplement to Family Practice Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you-re not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Susan Pincus, CPC, CHC, has over 17 years of healthcare coding and reimbursement experience, almost all of which has been in a multi-specialty environment. She was a healthcare compliance professional in a large academic medical center and currently has her own healthcare consulting practice. She is on the National Advisory Board of the American Academy of Professional Coders (AAPC), and is certified by the AAPC and the Health Care Compliance Association (HCCA). She is also an approved PMCC instructor. In 1997, the AAPC honored Susan with their prestigious National Coder of the Year award.

Today I will be sharing with you some information regarding how you can bill and get reimbursed for preventive medicine visits and for screening tests.  We are going to cover first the Medicare Initial Preventive Physical Examination or the IPPE, then I am going to talk about new screening services covered by Medicare for 2005.  I will mention proposed smoking cessation counseling by Medicare.  Then I will review some other preventive and screening services covered by Medicare.  Then I will switch gears a little bit and go into the preventive medicine visit, talk about it and then I am going to provide several preventive medicine scenarios and tell you how to code those scenarios.  We will talk about the advantages as well as the challenges of using preventive medicine codes and then we will talk about the combined problem-based and preventive visit and I will also provide several combination problem visit and preventive medicine visit scenarios and talk about how they should be coded.  And then at the very end I am going to give you two examples of visits that we will code together.

First let me give you the scoop on the new Welcome to Medicare Exam or officially the Medicare Initial Preventive Physical Exam or the IPPE.  This exam affects Medicare patients newly enrolled as of 01/01/05.  For example, if a Medicare patient enrolled in Medicare on 01/01/05 they have until 07/01/05 to get their IPPE.  Medicare will allow one preventive medicine visit only during the first six months of enrollment.  The visit maybe performed by a physician or the NPP, which could be a nurse practitioner, a PA or a clinical nurse specialist.

Let us talk about the deductible and coinsurance. Unfortunately, deductible and coinsurance apply to this benefit.  At the beginning of Medicare deciding to cover this benefit many physicians commented that there should be no out-of-pocket expense for this exam, but Medicare decided that there should be a deductible and coinsurance to this benefit.  The HCPCS code that you would use for coding this service is G0344.  The payment is approximately $97, which is comparable to the RVU for the CPT 99203.  This payment amount was also controversial at first and many physicians thought that the RVUs should be the same as the 99387, the preventive medicine visit for a new patient age 65.  Fortunately, a separate E/M sick visit at any level may be billed in addition to the preventive medicine exam if you use the modifier 25.  Now initially Medicare was going to limit the sick visit to a level 2, but then they later decided to allow any level of service in addition to the Medicare Initial Preventive Physical Exam.

The documentation requirements are pretty rigid.  What I would suggest is that you develop a documentation or a dictation template including all of these criteria to make it easier for your physician to remember to document these.  First you have to document the review of the medical and social history with attention to the modifiable risk factors for disease detection.  The medical history should include at a minimum the past medical and surgical history, illnesses, hospital stays, surgeries, allergies, injuries and treatments, current medications and supplements including calcium and vitamins.  And then on page 4 we continue with the family history with the review of family medical events, diseases that are hereditary or place the patient at risk.  And then the social history includes at a minimum the history of alcohol, tobacco and illicit drug use, diet and physical activities.

There also must be a review of potential risk factors for depression including current or past experiences with depression or other mood disorders.  It should be based upon the use of an appropriate screening instrument for persons without a current diagnosis of depression.  They are going to allow the physicians to chose from available standardized screening tests that are recognized by national medical professional organizations.

The documentation should also include the review of functional ability and level of safety and at a minimum, a review of the following areas: hearing impairment, activities of daily living, falls risk, and home safety.  The physical examination should include height, weight, blood pressure, visual acuity screen and other factors as deemed appropriate based on the patient's medical and social history and current medical standards.

Now on page 6, also included in the IPPE is the performance of an EKG.  If the primary physician does not perform the EKG during the visit, the patient should be referred to another physician to perform the EKG.  The HCPCS for the EKG is G0366 and it is separately reimbursable at approximately $27.  Now if for some reason your physician only interprets the EKG, you would bill the G0368, which is the professional component only.

Also included is education, counseling and referral based upon results of the exam and education counseling and referral including a brief written plan or a checklist provided to the patient for other screening and preventive services.

We are now going to review the billing and the coverage of some of these other screening and preventive services that Medicare is covering.  The first two are new, which includes the diabetes screening.  On page 7, diabetes screening is covered once every 12 months for patients with one of the following risk factors: hypertension, dyslipidemia, obesity, previous elevated impaired fasting glucose, previous identification of impaired glucose tolerance and/or 2 of 4 of these characteristics:

- Overweight.
- Family history of diabetes.
- History of gestational diabetes or delivery of a baby greater than 9 pounds.
- 65 years of age or over.

They will cover two screenings per 12 months period for patients they consider to have prediabetes and that is defined as a previous fasting glucose level of a 100-125, a two-hour post glucose challenge of 140-199.  This screening includes these following lab tests: The 82947, which is the glucose quantitative blood.  The 82950, the post glucose dose.  The 82951, the glucose tolerance test or GTT with three specimens.  The diagnosis that you should use for this is the V77.1, which is the special screening for diabetes mellitus.  With this screening test the deductible and the coinsurance do not apply.

Now onto page 8.  The other new tests that they are covering for 2005 are the cardiovascular screening.  This is covered every 5 years and you are supposed to use the lipid panel code CPT 80061. This lipid panel consists of the cholesterol serum total, the lipoprotein direct measurement, high-density cholesterol (HDL) and the triglycerides.  The diagnosis that you would use would either be V81.0, which is the special screening for ischemic heart disease.  The V81.1, which is the special screening for hypertension or the V81.2 which is the special screening for unspecified cardiovascular conditions. They also state that the physician can order other tests on the same day based on the results of these screening tests and of course this is paid under the clinical lab fee schedule.

Now I wanted to let you in on something you might not know about and that is some discussion that Medicare has concerning coverage of smoking cessation counseling.  They have finally realized that seniors have not been offered smoking cessation treatments at the same frequency as younger smokers and what they want to do is to evaluate the provision of tobacco dependence treatments in the Medicare population.  They are going to use unique and well-defined codes that allow for the measurement of the processes, outcomes and patient experiences.

Then for page 9.  What they are considering is coverage of two cessation attempts per year, each attempt may include a maximum of four intermediate or intensive sessions.  The patient and the practitioner may chose between intermediate or intensive cessation strategies for each attempt. The total benefit will cover up to eight sessions in a 12-month period. This draft decision was issued on 12/23/04 and it had a 30-day comment period. The proposed final decision was supposed to come on 03/21/05, however, I did look on the CMS Web site yesterday and I did not see any mention of this final decision, but it should be coming any day now.

Now let us turn to page 10 and I am going to review Medicare coverage of other screening services just as a review for you and how these should be coded and billed.  First the coverage of the flu/pneumococcal vaccine.  The flu is covered once each flu season. The flu vaccine product is coded with 90658, that is for a patient over 3 years old. The administration code is G0008 and the diagnosis that should be used is V04.81.  For the PPV it is covered once a lifetime or once every five years if the patient is at highest risk.  The PPV vaccine product code is 90732, the administration is G0009 and the diagnosis is V03.82.  The products are going to be reimbursed at 95% of AWP.

For the hepatitis vaccine the coverage is once a lifetime for patients at intermediate or high risk.  The codes that should be used would be 90746 for the hepatitis B vaccine adult dosage for IM use or the 90740 for the hepatitis B vaccine for dialysis or immunosuppressed patients and that is a three dose schedule, or the 90747 which is the same as above except it is a four dose schedule instead of a three dose schedule for the dialysis or immunosuppressed patients.  You would also bill the G0010 and I have here -unless an E/M is charged,- but this year they are allowing payment for administration of injections on the same day as an E/M service.  Again, the reimbursement for the product is 95% of AWP.

Let us go to page 11 and let us talk about the screening mammograms.  Medicare covers one baseline mammogram for a person 35 to 40 years old and then annually after 40 years old and there are several different codes to use based on whether you are doing the digital mammogram or the regular mammogram and of course, if you are only interpreting the mammogram you would use the modifier 26 with the 76092.  You would use the G0202 plus the 76083 for the digital mammogram.  The diagnosis to use for the screening mammogram would be the V76.11 for the high-risk patients or V76.12 for other patients.

For the screening Pap smear the coverage is one Pap smear once every 24 months or once every 12 months for women with an abnormal Pap in the preceding three years or if they are at high risk.  The code for obtaining, preparing and conveyance of the Pap smear is Q0091.  You would only code the physician interpretation if the physician actually interpreted the smear, which would be the P3001, the G0124 or the G0141.  The diagnoses that would be used V76.2 for the low risk patient, the V76.49 for the patient with no uterus or cervix and V15.89 for the high-risk patient.

Let us go on now to the coverage of the screening pelvic and breast exam.  The documentation for this exam must include 7 of the following 11 elements; it must include the inspection and palpation of the breast for masses, lumps, tenderness, asymmetry or nipple discharge.  The digital rectal exam including sphincter tone, presence of hemorrhoids and rectal masses.  And the pelvic exam including external genitalia, urethral meatus, urethra, the bladder, vagina, the cervix, the uterus, the adnexa and parametria, the anus and perineum.

The coverage for the screening pelvic and breast exam.  The pelvic exam including the breast exam is covered once every two years or more frequently for women at high risk.  The pelvic exam and Pap smear may be billed on the same day and the pelvic, Pap, and an E/M may be billed on the same day if there are separately identifiable services provided.  The codes for the pelvic and breast exam are the G0101 and the diagnosis that would be used would be the V76.2 for low risk patient, the V76.49 for patient with no uterus or cervix and the V15.89 for high-risk patients.

For the bone mass measurement coverage, Medicare covers one test every two years for a woman who has or is estrogen deficient and at clinical risk for osteoporosis, has vertebral abnormalities indicative of osteoporosis, osteopenia or vertebral fracture.  If they are receiving glucocorticoid therapy equal to 7.5 mg of prednisone or greater per day for more than three months.  If they have primary hypoparathyroidism or if they are being monitored to assess response to or efficacy of an FDA-approved osteoporosis drug therapy.

The codes that will be used for billing the bone mass measurement are the 76070-76078 or 76977 or 78350 or the HCPCS G0130.  There are many diagnoses that are covered for this bone mass measurement but most of the diagnoses would follow in these three diagnoses; V49.81, 627.2, or 627.9.

Medicare is also covering glaucoma screening and this glaucoma screening must include a dilated eye exam with intraocular pressure measurement, a direct ophthalmoscopy examination or a slit lamp biomicroscopic exam.  The coverage for the glaucoma screening is annual for eligible beneficiaries, those with diabetes mellitus, family history of glaucoma or African Americans age 50 or over.  And the codes that would be used would be the HCPCS G0117-G0118 and the diagnosis would be the V80.1.

The coverage of the colorectal cancer screening is for fecal occult blood, annually if 50 years of age or older.  A flex sig every four years. The colonoscopy every 10 years or every 2 years if you are at high risk.  The barium enema every four years or may be an alternative to the flex sig or the colonoscopy.  You cannot have all three.  The codes for the FOBT include the G0328.  For the flex sig you would use the G0104.  For the colonoscopy would be the G0121 or the G0105 for the high-risk patients.  Barium enema would be the G0106 or G0120 and the diagnosis would be the V76.51.

Now let us turn to page 16 and the last test we are going to discuss is the prostate cancer screening.  The coverage is annually for males 15 years old or older.  The digital rectal exam is not separately payable if it is performed on the same day as a covered E/M service and not preventive service.  The codes for the PSA would be G0103 and the code for the digital rectal exam would be the G0102.  The diagnosis would be V76.44.

Now I have listed here some very good Medicare resources for you to get more information on screening services or even other information that Medicare has.  This Web site www.cms.hhs.gov/medlearn is a wonderful Web site.  If you go to this Web site you can sign up for the Medlearn network mailing list and you can get a Medicare Preventive Services Educational Resource Web guide, which gives you sort of a quick and dirty of all the coverages of preventive services by Medicare.  Best of all you can get a catalog, the Medicare learning network products catalog, and all of the products in this catalog are free and all you have to do is order them online.  They also have Web-based training modules.  They have downloadable publications, which are very valuable.  They even have handouts that you can download and print and give to your patients or you can order those through that product catalog and these are very informative brochures that you can give your patients so that they understand what the coverage is and if they have any questions about the different coverages of the screening services.  They also have the Medicare prescription drug coverage information at this Web site, so I would highly encourage you if you have not gone to this Web site to go to this Web site and make yourself familiar with what is there and order some of the products that are there.  Also you can get other type of Medicare coverage information by just going to the www.cms.hhs.gov/coverage Web site and if you need to have information and coverage of anything you should be able to find it at that Web site.

Now let us switch gears a little bit from the strictly Medicare related screening information and let us talk about preventive medicine visits that can be billed to any payer or to the patient.  The definition of a preventive medicine visit is a routine physical without a problem or complaint or with a minor problem or complaint.  This includes or should include a comprehensive history and exam that is age appropriate.  However, the physician does not have to document the same criteria for a comprehensive history and exam in the preventive medicine visit as they do for a regular problem- focused visit.  Health and risk factors must be discussed and screening tests must be ordered and documented.

The CPT code is based on whether they are a new or established patients and the age of the patient.  The codes are 99381-99397.  The diagnoses codes that you would most often use although this is not a comprehensive list would be the V70.0, which is the routine general medical exam, the V72.31, which is the routine gynecological exam and the V20.2, which is the routine infant or child health check exam.

On page 18 let us talk about the advantages, but also the challenges of using the preventive medicine codes.  The advantages are you can collect your full fee whether it is from the patient, such as the Medicare patient, if the insurance company does not pay it or the payer does not pay it,.  But then also some payers pay very well for the preventive medicine visits and sometimes better than the regular visits.  So if you are not using the preventive medicine codes you may be missing out on some good reimbursement.  It is easy to code by the age, the physician does not have to try to decide what level of service to bill.  The documentation for the physician is much easier because you do not have any specific documentation criteria for supporting the comprehensive history or exam and you do not have medical decision making documentation that you have to have.  There are some challenges to using the preventive medicine codes.  The first challenge is encouraging the physicians to use the codes.  I have had some luck in encouraging physicians to use the codes but many times I have found that they do not even have the preventive medicine codes on the encounter form and when I see that they do not have them on the encounter form I highly encourage them to put them on the encounter form.

In order for the physicians to be able to use these codes there has to be both education of the physicians about the non-coverage of preventive medicine codes but also education of the patients.  What I would suggest is making up some type of brochure to give patients and explain in that brochure the non-coverage of preventive medicine services, so they understand when they first come to your clinic that they are going to be expected to pay for the strictly preventive medicine services.  Many Medicare patients do not understand that Medicare does not pay for preventive medicine services and so they are very surprised when they get a bill.  They really need to be told ahead of time and have it explained carefully to them.

Do not let your physicians fall into the trap of putting a diagnosis on a visit just because the patient is pressuring him or her to do that.  I have found that that often happens.  But when someone in the front office or the physician explains to the patient that he or she cannot do this because it is fraudulent billing and explains that they do not want the physician to get into trouble with the government, and explain that they will if they code a diagnosis that should not be on there.

What I would like to do now is to look at a few clinical scenarios and discuss how these scenarios should be billed.  Now there may be some situations where you may not agree with me on the coding of these, but let us go through this and let us just see what you think.

The first scenario is a 70-year-old Medicare established patient who presents for her annual gynecological exam.  She complains of occasional aches and pains, but she does not ask for and is not prescribed any medication.  The physician performs a comprehensive history and physical exam including a pelvic exam, a clinical breast exam and a Pap smear.  Now in my opinion under this scenario this is how it should be billed; you would bill to the patient the 99397, which is the preventive medical exam with the diagnosis, the V72.31.  You would then bill to Medicare the G0101, which is the pelvic and breast exam which Medicare covers using the diagnosis V76.2 and the collection of the Pap smear, the Q0091 with a diagnosis V76.2.  Now you may want to use the modifier 52 on the preventive medicine visit since you are actually carving out a part of that visit to bill to Medicare and the part of the visit you are carving out is the pelvic and the breast exam, so you may want to add a 52 modifier to the 99397 when you are billing it to the patient and you may want to reduce the fee somewhat as well.  Now even though Medicare does not allow you to use the 52 modifier with any E/M service, other payers will pay for the 52 modifier with the 99397.  I actually checked with the Georgia carrier to make sure that this was appropriate and they said it was okay; you may also want to check with your carrier to make sure that they feel it is okay for you to bill the preventive medicine visit to the patient along with the pelvic and breast exam to them and the collection of the Pap smear.

Now you noticed that I did not add a problem-focused E/M service to this scenario and mainly because even though she complained of occasional aches and pains she did not ask for any medication and the physician did not prescribe any medication.

Let us go to page 19 and let us look at clinical scenario #2.  A 46-year-old man presents as a new patient for an annual physical exam.  He was referred by his psychiatrist.  He has a history of schizophrenia, but it is well controlled with medication.  He is a smoker and occasionally notes a cough, but has no respiratory complaints currently.  The physician performs a comprehensive history including past immunizations and a comprehensive physical exam.  He suggests that the patient begin attending a smoking cessation program and encouraged him to diet and exercise.  The physician ordered screening labs including a PSA.  In my opinion you would bill this scenario with CPT 99386 with the diagnosis V70.0 and you might want to add 305.1 because he is a smoker.  Now in my opinion there is really not enough assessment of the cough and the smoking and there is not any assessment of the schizophrenia because the psychiatrist is treating the schizophrenia, so I would not use that diagnosis at all and I would only code this as a preventive medicine visit.

For the third clinical scenario a woman brings in her 5-year-old son who is an established patient to the physician's office for a school physical required by the private school he will be attending.  The physician performs an age appropriate comprehensive history and physical.  Speech, growth, development and behavior are assessed.  Immunizations are reviewed.  The physician discussed prevention of injuries for his age group, nutrition and dental care.  Medically appropriate lab tests are ordered.  The mother is concerned that her son is smaller than other children in his age group, but the physician reassures her that he is just a little below average height for his age and will probably catch up during this next year.  In my opinion you would code this service with the 99393 and using the diagnosis V70.3.

Let us now turn to page 20 and we are going to discuss the combined problem-focused or problem based and preventive visit.  These are the more difficult to try to discern, but we are going to go over some possibilities of how you can determine when a combined problem based and preventive visit should be billed.  Both visits, the preventive medicine service and the problem-oriented service, may be billed if the patient presents for a routine physical and complains of a significant problem, which requires additional work for the physician to perform the key components of a problem oriented E/M service.

Now how do you determine a significant problem and additional work?  If you are coding from the physician's documentation you have to look to see what the physician did for that problem-oriented visit.  If he just mentioned in the history of present illness that the patient had some other diagnosis or some symptoms, but he did not prescribe medication, he did not examine the patient further because of it, then I would not code a problem based visit and preventive visit. 

If in fact the physician does provide more services than he would ordinarily do for the preventive visit based upon a problem that was found at the visit then I would code both problem based and the preventive visit.  When you do code both you must add the modifier 25 to the problem-oriented service and for Medicare the combination charge cannot be more than what would have been charged for the preventive medicine service only.  Now I know some payers have refused to reimburse for both the preventive medicine and the problem based visit together.  They will only reimburse for one or the other.  But I would certainly check with the payer and when possible I would code both.

Let us look at the Medicare combination charge on page 21 and let us talk about how you would calculate the fee that would be billed to the patient whenever you have the combined visit.  It is a little confusing, though I am hoping that I have made it real clear for you on the slide.  Let us say, for illustration purposes only, that your fee for the preventive medicine visit 99397 is a $100 and let us say that your fee for 99212 is $60.  You would subtract your fee of $60 from 99212 from your fee of the $100 for the 99397.  That equals to $40.  Then you would calculate the Medicare patient's coinsurance amount.  You would also owe, in addition to the $40, that coinsurance amount only for the 99212 and of course the coinsurance amount of the 99212 would be 20% of the Medicare allowable.

In this example, let us say that that coinsurance amount equals $7.48.  The patient then is responsible for the difference in the fee for the 99212 and the fee for the 99397, which is $40, and then you add the coinsurance amount from the 99212 which is $7.48.  So the total amount that you would bill the patient for this combination visit would be $47.48 and then of course you would get 80% of Medicare for the 99212.  I hope that helps to explain a little bit of how to bill for the combination visit because it can be a little difficult to understand.

Let us take this first clinical scenario for the combined visit and let us see if you agree with me that this in fact should be billed as a combined visit.  In this first clinical scenario, a 35-year-old female established patient presents for her yearly gynecological exam.  The physician performs a comprehensive history and physical exam, but during the examination her physician finds what seems to be a palpable lump in her left breast.  He examines the breast more extensively including adjacent lymph nodes.  He asks additional questions concerning the history of breast cancer in her family.  In addition to the usual preventive screening lab and x-ray services, the physician orders a diagnostic mammogram rather than the screening mammogram because he has found the lump and asks her to return to the office in two days for the results.  Obviously the patient is very concerned with this finding and the physician answers her questions regarding the probabilities of the lump being malignant.  Now I have added a little additional information here that the physician documented additional work and the performance of a problem focused history and exam relating to the breast lump.  In this scenario, it is my opinion that I would bill the 99395, which is the preventive medicine visit, with the diagnosis V72.31.  In addition I would bill the 99212 with a 25 modifier with the diagnosis 611.72 for the breast lump.  Operator I think it is now time for us to open up the lines for questions.

Thank you Ms. Pincus.  Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time please press *1 on your touchtone telephone.  If your question has been answered or your wish to remove yourself from the queue, please press #.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1. 

Q & A Session:

Our first question comes from Debi Melillo of the Coding Institute.  Please state your question.

Question (DM):  Hi! Thanks so much.  Susan we had this question e-mailed to us right before the conference.  It reads; how do you code for a sports physical?

Answer:  Well, a sport physical is sort of the same code as you would do for a school physical.  If a comprehensive history and physical are performed I would use the preventive medicine code based on the age of the patient and then as the diagnosis I would use the V70.3 for the sports physical.

Question (DM):  Great.  I do have another question if I have time.

Answer:  Sure.

Question (DM):  It reads; how would you code a routine scheduled follow-up one year following the removal of the cancerous tumor when there are no complaints and no evidence of recurrence?

Answer:  Ooh! That is a tricky one.  You really would need to question the physician to get a little bit information on this one.  If, after questioning the physician, the physician says the visit was just for surveillance of the cancer recurrence then I would code it with the regular office visit with the diagnosis code of history of cancer.  However, if the patient is asymptomatic, they have no complaints and the main reason for the visit is really preventive and the physician is pretty clear about this then I would use the preventive CPT code.  I might go ahead and add the diagnosis of the history of cancer to that as well but if the physician is pretty clear that this really is just a preventive medicine visit, it just happens to be that the patient has had cancer, then I would go ahead and code it with the preventive medicine code.  But in this scenario you really need to talk with the physician and the physician needs to make clear in his documentation really what the reason for the visit is.

Question (DM):  Great.  Thanks.  Mandy do we have any questions or shall I continue?

Please continue.

Question (DM):  Okay, thanks.  This next one reads; if a Medicare patient does not remember if or when they have received a PPV in the past five years, will Medicare cover another PPV?

Answer:  Fortunately, yes.  Thank goodness Medicare does not require patients to give the physician an immunization record and they do not make the physician have to go back five years in the patient's medical record to try to determine whether the patient had one in the past.  So they say that if there is any doubt then you can go ahead and given them another PPV.

Question (DM):  Great and the final question reads; how would you code a preventive medicine visit when the physician has not documented a comprehensive history or exam?

Answer:  This is sort of a tricky one as well.  You have to remember though that the physician does not have to document a comprehensive history and comprehensive exam like he would for a problem focused visit or a problem based visit.  But let us say the scenario is that the physician is just performing maybe a GYN, pelvic and breast exam and this is to a non-Medicare patient and the physician really does not do a head to toe physical but really just concentrates on the GYN exam.  There might be several different alternatives that you could do.  Probably the best one would be to code it with a 99429, which is the unlisted preventive medicine service.  Now, I know that we hesitate to code anything with a 9 at the end of it because that means that we may have to submit more documentation at a later time to explain what the service is, but really that is the safest way to code the service. 

Another way that you might want to code it would be to go ahead and code the regular preventive service but maybe use that modifier 52 like we talked about before, that would sort of give the payer the indication that the physician did not do the head to toe exam, but just did a partial preventive medicine exam and of course, you would have to check with the payer to make sure that that 52 modifier can be used with an E/M service, if they would accept it.  That would be another alternative.  That last alternative that I think probably would not be as good as the first two would be to go ahead and code it with the regular E/M service based on the type of the level of exam, history exam, or the GYN exam--but then use the V70.0 diagnoses.  Like I said, that would be my third choice, but my first choice I think the best way to do it would be using the 99429, the unlisted preventive medicine service.

Comment (DM):  Thank you so much.  I have no more questions.  Mandy back to you.

Our next question comes from Deborah Jensen of Warner Family Practice.  Please state your question.

Question (DJ):  Hi! We do a lot of preventive in our office such as people with active illnesses--diabetes, hypertension, hyperlipidemia--what is the best way for us to report those and actually get paid?

Answer:  That is very difficult.  Do the patients come in on a yearly basis mainly for their preventive and then you also assess the diabetes and hypertension as well?

Comment (DJ):  All of our patients that are diabetic, hypertensive, even hyperlipidemia, asthmatic, we have them set up to come in like quarterly to see the doctor and then we have a nutritionist, dietitian, so we try to get them over there to see Brad so they can get some counseling with their diet and exercise and all of that.  I mean I know the 99401-99404 codes are for people with inactive.

Answer:  Well you know, I think most of your visits probably would not be considered preventive medicine visits because they are coming in with active chronic illnesses and you are assessing those chronic illnesses.  The only time I would code a combination would be if they are coming in like for one of those quarterly visits and one of the physician also counseled them on preventive services, ordered the screening mammograms, did the Pap smear and other screening services--then maybe on that once a year visit, if that is what the physician does once a year, then I might code it a combination.  But it sounds like most of your patients are coming in really with active chronic conditions and I would code those with the regular codes.

Comment (DJ):  Thank you very much.

Again Ladies and gentlemen, if you would like to state a question, please press *1 on your phone now to be placed into the queue.

At this time, we have no questions.  I would like to turn the program back to Ms. Pincus for any closing comments she may have.

Okay let us go through a couple of these other scenarios that we have not finished and I think that might help in determining these combination visits that are so tricky.  The next clinical scenario is a 65-year-old male who enrolled in the Medicare program one month ago, presents to the physician for his initial preventive physical examination and follow-up of hypertension.  The patient is on beta-blocker therapy.  The physician performed and documented all seven components of the services including the performance of an EKG in his office.  The EKG was normal but after the physician took his blood pressure in both arms, he noticed that it was elevated.  When asked, the patient said that he often takes his blood pressure at the local pharmacy and that lately it had been a little higher than usual.  The physician decided to adjust his medication accordingly and requested that he return in a month unless he had further problems.  Now in this scenario, the physician documented a problem-focussed history, expanded problem-focussed exam and moderate decision-making relating to his hypertension.  And in this case, I would code the combination visit using G0344 which is that IPPE exam, remember he just enrolled in the Medicare program one month ago so they are giving him the IPPE exam and I would use the diagnosis V70.0 and then the G0366 with diagnosis V81.2 is the EKG both components of the EKG but then in addition I would bill the 99213-25 with the diagnosis you can use either V401.1 or V401.9 based upon what the physician gives you.  So in this case, really he is doing this initial exam, preventive medicine exam that Medicare now is paying for, but then the physician is also adjusting his medication, he is assessing his hypertension, he is getting more history about the hypertension once the physician noticed that his blood pressure was elevated.  So in this case, I would code both services.

Now let us go to the clinical scenario #3.  A mother brings in her 2-year-old daughter for her regularly scheduled routine healthcare.  The mother notes that the child has been more irritable than usual and has had difficulty sleeping at night.  The physician here is performing an age appropriate comprehensive history and exam.  During the exam, the physician notes a fever of 100 degrees and inflammation of the right ear.  The child's mother did recall that for the past three days, her daughter has pulled at her right ear and the physician diagnosed acute right otitis media and prescribed medication.  Regarding the preventive checkup, the physician did review immunizations, did check the child's speech, blood pressure, growth and development, which were all normal.  The risk factors, good parenting practices, nutrition and dental care were also discussed.  However, the physician did document the problem focussed history exam and low-complexity decision-making relating to this otitis media.  In my opinion you would bill the 99392 with the diagnosis V20.2 and then in addition, the 99212-25 with the diagnosis of the otitis media 382.9.  Now I know there are some Medicaid programs that have special health check code that you will of course use the codes that are appropriate for your state Medicaid program.  But I would also know that many of the Medicaid programs will allow you to bill a regular routine health check code and a program focused visit code in addition.

Let us look at the last page in the -how would you code these scenarios?-  This gives us a little bit more information and we may have some differences of opinion here.  Let us go through this first scenario.  A 68-year-old established patient presents for annual physical complaining of a two-day episode of allergy symptoms.  The physician completes a comprehensive history and exam as part of the preventive medicine service.  The HEENT exam is noted as normal.  The physician counsels the patient regarding diet, exercise and injury prevention.  Risk factors are identified and interventions are discussed.  Medically appropriate screening lab test and diagnostic procedures are ordered.  The physician renewed her prescription for Allegra-D and told her to return if her symptoms worsened.  So how would you code this scenario?  This is not quite as black and white as the others were.  She did come for annual physical but she did have allergy symptoms.  When he examined the ears, nose and throat, they were normal.  The physician however did renew her prescription.  In my opinion, the physician really did not, based on this documentation, do enough additional physician work to charge a problem-oriented exam.  You may disagree with me on this.  But what I would code this would be just a regular preventive medicine exam, the 99397 with the V70.0.

On this last scenario, we have a 23-year-old established patient who presents for her routine annual physical.  During the comprehensive history and exam, the physician notes that the patient seems very depressed.  After he questioned her further she mentioned that she had lost her mother in a terrible car accident just two weeks ago and has not been able to eat or sleep properly.  She asks if she could have an antidepressant and/or sleeping pill to help her.  The physician counseled the patient regarding the four stages of grief and they discussed the pros and cons of taking antidepressant medication.  After a 45-minute discussion, they both agree to try a low dose of a popular antidepressant medication.  Medically appropriate screening lab tests and screening chest x-ray were ordered.  The total time spent with the patient was one hour and she was asked to return in one month. 

Well in this scenario, not only do you have the questions -do you add a problem visit along with the routine preventive medicine visit- but you have the scenario of the 45-minute discussion in an hour long visit.  So how would you code this?  Well in my opinion, you would code this with the preventive medicine code, the 99395 with the V70.0 because you did perform a comprehensive history and exam and ordered the screening lab tests.  But in addition, you had a 45-minute discussion with the patient.  Now with the scenario that you can bill an E&M visit based upon time if more than 50% of that time was spent in counseling the patient, I would then also code a 99215-25 because the 99215 has 40 minutes in the description of the code and he spent 45 minutes with the patient.  And I would use the diagnosis the depression diagnosis 311.  So I would bill on 99395.  In addition, I would bill the 99215-25.