Primary Care Coding Alert

Family physicians (FPs) and coders often debate whether a patient visit is billed appropriately as an office/outpatient evaluation and management (E/M) service (99201-99215) or an annual physical (99381-99397). Many patients, particularly the elderly, present with several chronic health problems that require periodic evaluation and treatment. Some FPs argue that this justifies reporting the service with a regular E/M code rather than a preventive-medicine code (99381-99387, new patient; 99391-99397, established patient).

According to CPT coding guidelines , this is not correct. Physicians must separate the portion of the service that is problem-oriented from the portion of the service that is the preventive, overall health screening.

According to CPTs definition of preventive-medicine services, if an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive-medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive-medicine service.

The key is to know when the additional workup is significant enough to warrant a separate code. You must have an illness that requires its own, separate evaluation, with a history, physical exam and medical decision-making all related to that separate problem, says Cindy Headley, reimbursement director for the Order of the Sisters of St. Francis Medical Group in Peoria, Ill.

Deborah Lief, CPC, manager of coding compliance for ProMedCo, a physician practice management company in Ft. Worth, Texas, advises that some physicians are billing separate codes that are not really outside a normal annual physical.

If a patient goes in for an annual physical, nine times out of 10, you are going to have the patient say, Oh, I have itching here or a rash here. That is the one time per year for the patient to tell the physician all the stuff that is bugging them, Lief says. That doesnt mean that its not an annual physical.

Many physicians and coders disagree with her assessment. But, Lief says, the issue is primarily a problem when billing for Medicare patients, which indicates that the motive for billing more office/outpatient E/Ms is receiving payment. If tomorrow, Medicare decided to pay for annual physicals, physicians would not argue this anymore, she states. Everyone would know what an annual physical is.

If the physicians documentation fully supports the reporting of a separate E/M code, Medicare will reimburse the office/outpatient visit. For Medicare patients, however, the office is not allowed to charge the patient the full cost of the visit for the annual physical exam that occurred on the same day, even if a waiver (advance beneficiary notice) is signed.

If the physician bills a separate E/M for a problem-oriented service on the same day as a preventive-medicine check, the reimbursement for that level of E/M must be subtracted from the offices normal charge for an annual physical, and the Medicare patient pays the difference.