Primary Care Coding Alert

Although getting paid for a preventive exam and a problem E/M service on the same visit may seem like an impossible feat, here are six ways to increase your chances for reimbursement.

1. Code for Both With -25. We're talking about a very common occurrence in family practices the patient comes in for a preventive exam, and the FP discovers a problem that must be treated separately. Use the proper-level preventive medicine services code (99381-99397) depending on the patient's age and whether he or she is new or established. In addition, code the appropriate-level E/M office or other outpatient service code (99201-99215) depending on the complexity of the problem, says Lynn Handy, LPN, CPC, director of professional development, consulting and auditing services at Revcare, a healthcare revenue management company in Cypress, Calif., and a Professional Medical Coding Curriculum (PMCC) instructor through AAPC. Attach 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 office visit code to show that it is separate from the preventive service.

When you choose the E/M level for the problem visit, try to stay away from higher levels, Handy says. If the patient is sick enough to warrant a high-level E/M, Medicare will wonder why he or she required the preventive service in the first place and may invite closer scrutiny or deny the claim.

2. Match Up ICD-9s. "One of the keys to getting paid for the preventive/problem combo visit is linking the diagnosis codes properly to show the medical necessity of both services," says Marta Kramer, CCS-P, a health information technician at Fairview Lakes Regional Medical Center in Chisago City, Minn. Link a V code (such as V70.0, Routine general medical examination at a health care facility) to the preventive service code, and the diagnosis(es) of the problem(s) encountered to the office visit code.

3. Carve Out the Cost. Medicare does not reimburse for preventive exams, so the patient will be responsible for that portion of the visit. But you do have to bill for both services, Handy emphasizes. Medicare will deny the preventive service and pay the E/M, assuming it is otherwise covered under Medicare. The physician may charge the patient the amount that the physician's current established charge for the preventive medicine service exceeds his or her current established charge for the covered visit.

Medicare reimburses the problem visit based on its usual fee schedule for that service. For example, the physician's usual charge for the preventive service is $100, his usual charge for the problem visit is $50, and the Medicare-allowed amount for the problem visit is $40. If the patient has met her deductible for the year, Medicare will pay $32 (80 percent of $40), and the patient will be responsible for $58 (i.e., the $8 coinsurance on the problem visit plus the $50 difference between the physician's usual charges for the two services).

Some commercial carriers do, however, cover preventive services, and it is worth appealing if they deny the bill due to the combination of the services. Notify patients before the visit that their insurance may exclude preventive services. If they have to pay out-of-pocket, they will appreciate the warning and may even help you if an appeal is necessary.

4. Document Separately. "The doctors need to pay extra attention to documentation for preventive/problem visits," Handy says. "Auditors like to see separate notes for each service." For the preventive visit, FPs will document a comprehensive history, a comprehensive exam and some type of counseling, but not medical decision-making. On a separate piece of paper, if possible, the doctor will document the problem visit, which includes a separate history and exam and medical decision-making. Physicians cannot include the history and exam from the preventive visit as components in the problem visit. "The physician cannot get reimbursed for the same service twice," Handy says.

Physicians must also resist the temptation to help their patients avoid out-of-pocket costs by turning preventive services into problem-oriented ones. It's possible to document the visit so it appears that the patient initially came in for a problem visit, but that is fraudulent if he actually came in for a preventive service.

Some practices that have many preventive/problem combo visits have a special form for these particular visits. One side of the form aids in documenting the office visit, and the other aids in the physical examination.

5. Appeal. If these visits are clearly separate and you have attached modifier -25, you deserve to be properly paid. The most common reasons insurers list on explanation of benefits (EOB) forms for the denials are "redundant," "not normally performed on the same day or in the same session" or "unbundled." None of these are acceptable reasons to deny the special circumstances surrounding the preventive/problem visit.

In your appeal letter, you should reference the CMS policy on billing a medically necessary visit on the same occasion as a preventive medicine service as detailed in the Medicare Carriers Manual (MCM), section 15501.E. Also, explain to the carrier that the visit and services are properly coded according to CPT guidelines, which are accepted by CMS.

"I won most of my appeals on this subject by simply photocopying the preventive medicine section of CPT that states that an E/M can be billed in addition to a preventive and sending payers that along with the documentation," Handy says. Include the documentation with your appeal letter and inform the carrier that you have sent a copy of the letter to the patient. Sending a copy of the appeal to the patient not only keeps him or her apprised of the situation but may spur the patient to help the practice get paid (the patient knows that if the insurance company doesn't pay, it will come out of his or her own pocket). Sometimes, just showing the insurer that its customer is aware of an appeal can help get the claim paid.

6. Check Your Payer Contracts. Know what preventive services are covered under your contracts. "You really need to know what your payers will reimburse for," Kramer says. Medicare covers some preventive services, but patients are responsible for charges on the noncovered services. Other insurers also specify what preventive benefits they will reimburse. If a practice knows what preventive services are covered under its payer contracts, it can properly bill the insurer initially, and sometimes avoid the denial and appeal, Kramer says. And knowing what preventive services are covered can help you educate patients on the parts of the bill that may be their responsibility.