Primary Care Coding Alert

No codes are more common for family practices than those for office/outpatient evaluation and management (E/M) services (99201-99205, new patient; 99211-99215, established patient). So, getting the maximum allowable payment for these services is vital to your groups survival.

Here are five tips for improving E/M coding, documentation and reimbursement:

1. Clarify the difference between a preventive-medicine service and an office sick visit. Family physicians either report preventive physicals the same way they report problem-oriented visits, or they report almost all visits as annual physicals when the patients actually are evaluated for a problem. But there is a big difference between the two services.

A patients annual physical is a screening examination designed to check the patients health status to find out whether something is wrong and to make sure the patient is still healthy or continues to do well with existing treatments. These visits should be reported with the preventive-medicine services codes (99381-99387, new patient; 99391-99397, established patient). Select the code appropriate to the patients age. Reimbursement for these codes varies according to payer. Private payers that cover preventive exams will limit payment to once per year. Medicare, in fact, does not cover these visits at all. The patient is responsible for paying.

Some physicians tend to report preventive services as regular office/outpatient visits and assign an E/M level, which is covered by the patients insurance. Physicians often ask me about this, says Deborah Lief, CPC, manager of coding compliance for ProMedCo, a medical services company based in Fort Worth, Texas. I try to keep it simple. I tell them, if the patient comes in with a chief complaint, that is an office visit. If they come in for a scheduled exam, use the preventive-medicine codes. If I am doing chart audits, I always look through Medicares eyes. If I open up a chart and it says, annual physical, I close it and dont need to read anymore. I mark it 99397 (periodic preventive medicine reevaluation and management of an individual ... 65 years and over) and move on. That is what a Medicare auditor is going to do.

Some physicians get used to writing physical or annual physical for almost every patient, says Deborah Ice-Turner, CPC, billing supervisor for Internal Medicine Group, a multiphysician practice in Lawrence, Kan. And many patients wait to be evaluated for most of their health problems until they have the annual scheduled visit. CPT indicates that for patients who present for an annual physical and have an additional health problem requiring a significant separate workup, physicians should report the appropriate preventive-medicine code and an office/outpatient E/M code with a -25 modifier (significant separately identifiable evaluation and management service by the same physician on [...]