Primary Care Coding Alert

Preventive service is a classic example of an area where good medicine doesn t necessarily result in good reimbursement.

 

During the course of a year, family physicians (FPs) perform scores of preventive exams or annual physicals (99381-99387, initial preventive medicine; 99391-99397, periodic preventive medicine), which medical professionals agree are vital to a patient s health and well-being. However, most insurers  including Medicare  won t cover annual checkups, instead shifting the financial burden to the patient and creating a disincentive for patients to see their physicians regularly.

 

Family practices can counteract this problem by recognizing when a preventive service is simply an annual checkup  and when all or portions of the encounter can be coded and billed as an office or outpatient visit that will be paid by the insurer. These situations may occur when a problem or condition is discovered during a preventive exam, or when the visit can legitimately be considered necessary surveillance of chronic conditions.

 

 

FPs and coders must first recognize circumstances when only a preventive service may be reported. Typical annual checkups may include well-woman care with a breast exam and Pap smear, periodic sports or school physicals, and annual checkups for patients who raise no noteworthy concerns during the visit.

 

For instance, a 55-year-old male is seen for his checkup and asks the physician to inspect areas on his hands and arms where the skin has darkened. During the overall physical examination the FP notes that the change is simply discoloration due to aging. In this instance, because no significant new problems were evaluated or treated, only 99396 (periodic preventive medicine, 40-64 years) may be reported.

 

 

Coding becomes less straightforward when new conditions are evaluated during a preventive service. FPs and coders must recognize when the patient introduces a complaint that requires a significant and separately identifiable service, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J. When this occurs, physicians may report both a preventive service code and an outpatient visit code.  However, simply discussing a problem during the checkup doesn t automatically mean it can be billed as a separate E/M service, she warns. Instead, it must be clear that the doctor is proactively evaluating and treating another problem.

 

During her well-woman exam, for instance, a 30-year-old established patient complains of mild vaginal itching and discharge. The FP questions the patient further about her symptoms and, upon examination, diagnoses vaginitis (616.10). The physician recommends that the patient purchase over-the-counter suppositories from the pharmacy, advising her to return if the condition hasn t cleared up in a few days.

 

In this case, the physician will report the preventive care code (i.e., 99395, periodic preventive medicine, 18-39 years) along with an outpatient visit code that would be determined by the level of service provided (e.g., 99213). The latter code would be appended with modifier -25 to identify it as a significant and separately identifiable E/M service.

 

Correct linkage of diagnosis codes is vital to payment in cases like this, coding experts note, and typically at least two diagnosis codes are reported. In the example above, coders would report ICD-9 code V70.0 (routine general medical examination at a health care facility) along with appropriate codes to describe special screenings conducted (e.g., V72.3, gynecological examination). These codes would be linked with 99395. The vaginitis code, 616.10, would be linked with the E/M code.

 

In another case, a 50-year-old patient comes in for his physical and wants to talk to the physician about increased frequency and intensity of headaches. Besides the general exam, the FP will take additional history, expand the physical exam to focus on systems that might contribute to the headaches, consider a variety of treatment options and prescribe medication after diagnosing migraines. This type of visit, Brink says, would be reported with preventive service code 99396 (& 40-64 years) and an outpatient code like 99214, with modifier -25. Diagnosis code V70.0 would be reported with 99396, while 346.10 (common migraine, without mention of intractable migraine) would be linked to the office visit code.

 

Coders can play a big role in ensuring that the practice receives proper reimbursement when services other than prevention were provided. Coders should review the documentation closely, even when the FP has noted  annual exam on the patient chart. If the coder recognizes that further services were provided, an additional E/M code can be legitimately reported.

 

 

When reporting both a preventive and problem-oriented service to Medicare, the FP s total charges can t total more than the charge for a preventive exam. Medicare rules state that, if performing a preventive exam and problem-oriented exam on the same day, the physician can bill Medicare for the portion of the visit that was problem-oriented, Brink says. The physician would then bill the patient the difference between the charge for the preventive exam and the charge for the problem-oriented exam that will be paid by Medicare, plus any coinsurance and deductible that the patient owes on the problem-oriented service. For example, if a practice normally charges $120 for the preventive exam, and the charge for the problem-oriented exam is $80, the physician can bill the patient $40, plus the coinsurance or deductible.

 

 

Some practices require Medicare patients to sign an advance beneficiary notice (ABN) for preventive services. However, coding experts say this is not necessary. ABNs are required only when the services provided are covered by Medicare but might be denied as medically unnecessary in a specific instance. Preventive care doesn t fall into this category, but instead is considered  noncovered by Medicare and may be billed to the patient without a signed ABN.

 

 

 

Yet another scenario challenges coders reporting preventive services. Some patients, particularly the elderly, suffer from a number of chronic conditions that must be monitored and regulated on a regular basis. While this ongoing care might be provided only once a year, it may be reported as a problem-oriented office visit (payable) rather than a preventive service (nonpayable).

 

 A patient may schedule a  physical once a year, says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City.  But during the visit you address a number of chronic problems. These could comprise the bulk of the notes documented in the patient record, which may allow the practice to bill an E/M code.

 

Physicians and coders must be educated to view  and report  annual encounters of this nature as office visits rather than preventive services. Appointment staff may simply log  physical as the reason for the patient s visit, or the physician may begin documentation with a note that the patient was seen for her  annual checkup. This custom undermines a practice s ability to support a problem-oriented code when submitting claims. Instead, Fick says, physicians should be conscientious about documenting what they actually do during the visit.

 

For example, a 64-year-old female patient with type II diabetes, hypertension and high cholesterol schedules a visit once a year.  When the patient calls, she may say she s coming in for her physical, Fick explains.  The physician may simply accept that as the primary reason for the visit, which would indicate to payers that the service shouldn t be reimbursed.

 

On the other hand, he says, the physician should focus the encounter on the patient s existing conditions, and conduct the history of present illness and review of systems as an evaluation of these problems. This allows the practice to legitimately report the visit as with an outpatient code (e.g., 99214). At the end of the appointment, the FP can also provide typical preventive services such as ordering relevant blood work and laboratory tests, referring the woman for a mammogram and documenting that he will call the patient with results of the Pap smear.

 

In this scenario, Fick says, the patient s diabetes, hypertension and cholesterol levels should be recorded in the first three diagnosis fields on the claim (e.g., 250.00, diabetes mellitus without mention of complication, type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, not stated as uncontrolled; 401.1, essential hypertension, benign; 272.0, pure hypercholesterolemia). The routine medical examination code (V70.0) would be listed last.  It s a matter of the physician truly thinking about what services are being provided and making sure the documentation reflects this work.

 

Fick cautions, however, that FPs should not take this approach to its extreme.  Some patients suffer from chronic conditions that are being monitored by other specialists like pulmonologists or urologists. However, they come to their FP for an annual checkup. The physician could not, in this case, bill a problem-oriented examination based on those chronic conditions, but would report only the preventive services code.