Primary Care Coding Alert

Question: We often bill well woman and sick visits on the same day if the sick visit warrants a separate code. We use a modifier 25 with the E/M code. One of our insurance carriers recently started processing the E/M code at 50 percent of the allowable and states, "This procedure has been paid at 50 percent of the reasonable and customary rate, due to multiple procedures performed on same date." Does that multiple procedure rule apply to E/M codes? Should I just tell my physicians to reschedule the well check and E/M visits for two separate dates, so that we don't run into this problem?

New Hampshire Subscriber

Answer: E/M services and multiple procedures do not have the same CPT® rules, but payers are free to establish any rules they want in this regard. Most likely, their rationale is that you did not make the appointment twice, did not use the room twice, the patient did not see the provider twice, and you did not use office supplies twice. Some payers may also argue that elements of the history and exam are not necessarily repeated. Because of that, they are keeping part of the money.

Try this: As you noted, one option is to have your practice reschedule either the problem visit or the well woman exam (WWE), instead of trying to fit everything into one visit. Keep in mind this will take patient education to avoid misunderstandings about the services you will provide when your patients schedule their WWE. Your patients may also see it as a hassle and inconvenience, and the resulting negative patient relations must be weighed against the lost revenue of providing both services at the same encounter.