Primary Care Coding Alert

Aetna's new dual-service rule clears payment hurdles

Your imagination isn't running wild--payers are being notoriously stingy when it comes to reimbursing same-day problem-oriented and preventive medicine services. But these tips and a policy victory should reduce your denial rate.

Before appealing an office visit rejection with a well exam, run through this checklist:

Attach Modifier 25 to the Sick Visit Code

Verify that you appended modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the  procedure or other service) to the problem-related code, not the preventive medicine service. The family physician performs the office visit as a separate and significant service on the same day of the well exam, says Victoria S. Jackson, president of OMNI Management Inc. in California.

Link Each E/M to a Different Diagnosis

Review the claim and make sure you submitted different diagnoses for the sick visit and the well exam. -The visit doesn't have to contain a different diagnosis, but two ICD-9 codes help substantiate the E/M's significant and separate nature,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Example: An FP completes an established patient annual exam for a 6-year-old boy. The mother mentions that the child's asthma is acting up and that he needs a new prescription. The physician then spends 15 additional minutes on a history, examination and medical decision-making for asthma care. The stethoscopic exam reveals that the child has minor wheezing, which the FP decides doesn't require a nebulizer treatment but necessitates a change in prescription.
 
Solution: You should report the preventive medicine code (99393, Periodic comprehensive preventive medicine reevaluation and management of an individual - late childhood [age 5 through 11 years]) linked to V20.2 (Routine infant or child health check) and also charge the problem-related portion with 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient -) and the asthma diagnosis (such as 493.02, Extrinsic asthma; with [acute exacerbation]).

Encourage 2-Entry Documentation

Anticipate that insurers will request chart notes to support modifier 25 claims and encourage your FPs to create iron-clad documentation. Visually separating the services will help show the payer that the problem-related E/M -meets the test of water,- Jackson says. -The physician doesn't have to write the notes on a separate sheet, but the modifier 25 service must contain a history, evaluation and treatment.-

Problem: You-ve dotted your i's and crossed your t's to no avail. -We follow the modifier 25 guidelines and submit correct claims, but insurers keep bundling the problem-related service into the well check code,- says Pam Hunt, insurance and billing specialist at Physicians Caring for People in Tyler, Texas.

Explanation: Many insurers, despite CPT, will not pay for a preventive medicine visit and problem-oriented visit provided to the same patient on the same date, says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

Victory: AAFP has had success in addressing this issue with payers. -Aetna is changing its policy to allow both services, and the AAFP is trying to get other payers to do the same,- Moore says.

Other major insurers that still won't pay for the sick visit include United HealthCare and Champus/Tricare.

Evaluate Practice Management Strategies

For payers that continue to bundle office visit services with modifier 25 into well exams, consider two tactics:

1. Reschedule preventive medicine services. -If a patient's sick condition requires a significant and separate E/M service from the well check, you could suggest the patient return for the preventive medicine service,- Jackson says. Downfall: You-ll have to weigh the inconvenience this could cause the patient and the negative public relations this could generate.

2. Make patients responsible for same-day office visit payments. -One office used signs to notify patients that because some insurers wouldn't pay for office visits on the same day of a well check, patients would have to pay this portion,- Jackson says. Caution: Before adopting this method, verify that your major payers consider the office visits noncovered, rather than bundled. The contract must also allow you to balance bill patients for noncovered services.