Primary Care Coding Alert

Question: Please suggest how I should code the following typical scenario:
 
A 38-year-old established patient presents for checkup of chest pain, edema and anxiety attacks and requests a wellness exam. The doctor documents a comprehensive history and exam and diagnoses the patient with angina, edema, anxiety/depressive disorder, right breast mass, and degenerative arthritis of the knees and high-risk sexual behavior. In addition to ordering a stress EKG, diagnostic mammogram, comprehensive metabolic panel, thyroid panel, complete blood count (CBC), lipid panel, EKG and chest x-ray, the physician spends 15 minutes counseling the patient regarding her sexual practices and general health and wellness.
 
Should I charge a wellness code, an E/M code for the multiple diagnoses, and a counseling code to address the high-risk sexual behavior and other risk factors?

Oklahoma Subscriber

Answer: Depending on payer and scenario specifics, you have a few options:
 
1. Medicare/CPT way: If your family physician (FP) provides preventive medicine services and a problem-oriented office visit to a Medicare patient, you should separate the well and sick services.
 
If the problem-oriented service is significantly identifiable from the well exam, report both 99395 (Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender- appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; 18-39 years) and an appropriate office/outpatient visit code (such as 99212-99214, Office or other outpatient visit for the evaluation and management of an established patient ...).
 
Append 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 sick visit based on Medicare and CPT rules. Modifier -25 indicates that the FP performed more than the well exam's age- and gender-related services.
 
The chest pain, edema and anxiety attack evaluations in your example may warrant a separate E/M code, such as 99212-99214. Separate coding depends on how well controlled these conditions are and how much extra work they involve.
 
For instance, if the conditions are well controlled, and the FP simply notes that as part of the preventive medicine history, you probably shouldn't code a separate encounter.  However, if the physician addresses each of those problems in his history and physical exam and he documents the work associated with a problem-oriented visit, the documentation may justify separate coding. 
 
You shouldn't, however, break out the test ordering and counseling. A preventive medicine service includes ordering age-appropriate tests and providing wellness counseling, such as sexually transmitted disease prevention.
 
Before billing two same-day E/Ms, check your payer policies. Some contracts don't cover both services. In this case, your FP must decide how to handle these situations:
 
2. Bill only one service. (If you submit both the preventive medicine service and the office visit, the payer will reimburse the lesser-valued code.)
 
3. Reschedule physicals for patients whose medical conditions at the time of a well exam require a lot of attention.