Wiki Adult Physical and Well-Woman

[cbosi1]

I need some help please.

We are a PCP and saw a new patient in March for her Adult Annual Physical. She deferred the PAP and vaginal exam. She came back in May requesting a pap and followed up for lab results. (Initial lab results were given to her over the phone by a nurse, but they were reviewed with her and a plan of care was discussed by the PCP.) She has a commercial Cigna plan that covers an adult physical and a well-woman exam per calendar year.

In May - I do not think that the provider did all of the components of a comprehensive exam. There was not a comprehensive history done; other than stating "not reviewed (last reviewed 03/03/2024)" for each Family, Social, GYN and Obstetric history sections. Complete HPI. ROS states "ROS as noted in the HPI". A vaginal exam was completed with pap collection. However, there were 11 other organ systems documented in the Exam section. Am I wrong? Is this a complete well-woman without a comprehensive history, ROS, counseling, etc.?

March: 99386 w/ Z00.00 and Z68.32, 96127 w/ Z13.89

May: 99213 w/Z01.419 and R94.6, 99459 w/ Z01.419

I feel pretty confident that in order to have both exams covered at 100%, the same provider or same-specialty provider cannot do both exams. Is that correct? The patient is very upset with us and demanding that we file as a well-woman exam because the visit was applied to her deductible. In my experience, even if we were to bill as a well-woman exam, this would not be covered at 100% under preventive benefits and would be denied as max benefits met and become patient responsibility, which would cost her more out of pocket. Is that correct?

 

[Pam Warren]

We should never code based on what will get paid. We code based only on that which was actually done. Was there a complaint/illness that was discussed, i.e. did the lab work result in symptom management or diagnosis? If not, and there is only a screening component, you can't bill an E&M. Preventive exams don't have specific documentation guidelines in the same way E&M services do/did. In fact, CPT tells us that the 'comprehensive' nature of these codes does not align with the comprehensive exam required in E&M codes. We don't count 'bullets' in preventive exams.
Bill the preventive exam w/pap for the second visit, and if there's a coverage issue with two preventive exams in a single year, that's unfortunate, but it's what was done (at her request). But more importantly, billing a service specifically for coverage reasons, when a different type of service is performed, is considered fraudulent.

 

[cbosi1]

We should never code based on what will get paid. We code based only on that which was actually done. Was there a complaint/illness that was discussed, i.e. did the lab work result in symptom management or diagnosis? If not, and there is only a screening component, you can't bill an E&M. Preventive exams don't have specific documentation guidelines in the same way E&M services do/did. In fact, CPT tells us that the 'comprehensive' nature of these codes does not align with the comprehensive exam required in E&M codes. We don't count 'bullets' in preventive exams.
Bill the preventive exam w/pap for the second visit, and if there's a coverage issue with two preventive exams in a single year, that's unfortunate, but it's what was done (at her request). But more importantly, billing a service specifically for coverage reasons, when a different type of service is performed, is considered fraudulent.

I apologize, think perhaps I wasn't clear in my post. The patient had abnormal labs at her adult physical in March and a nurse called her with those results and scheduled her to come back in 4 to 6 weeks for repeat lab tests. She then came in to discuss those results and requested a pap be done at that time. I know that we can only bill what was actually done as opposed to billing for coverage reasons. While there aren't specific documentation guidelines, there are other components to a well woman exam that are supposed to be performed when billing for it. According to CPT, preventive medicine visits are “comprehensive preventive medicine evaluation and management services of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”

Billing a preventive exam when only a vaginal exam and pap smear were performed seems fraudulent to me.

I really only listed the information about her being upset that it applied to deductible in my post as I am trying to explain to the patient that we did not do a full preventive exam and cannot bill for something that we did not do. And then my secondary question was - even IF we did complete a well woman exam, it would not be covered at the 100% benefit that she thinks it will be covered at since the same provider or same-specialty provider cannot do both exams, correct?

If you are saying that the information that I provided DOES meet the rules for billing a preventive exam without the "age and gender appropriate history, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures." then I am happy to bill it as a well woman exam for her. (And wait in joyful anticipation to revisit this when her new bill arrives. Just kidding, obviously.)