Wiki E&M vs Preventative

[jbrandt]

Hi,
I'm wondering if anyone in oncology uses preventative CPT's when the patient has no other diagnosis except family history of cancer. If there's no problem identified during the visit & the only reason for the visit is surveillance, isn't a preventative CPT more appropriate than an E&M? We have some payers denying the E&M code when billed with a preventative diagnosis (V codes). Thanks!

 

[ValerieBatesHoffCPCCPMA]

Counseling Risk Factor Reduction (99401 - 99404)

E/M guidelines:

These codes are used to report services provided face-to-face by a physcian or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management services that may be reported separately when performed. Risk factors reduction services are used for persons with out a specific illness for which the counseling might otherwise be used as part of treatment.

Here are some articles that might be helpful.

http://www.kumc.edu/gec/prof/gcicd9.html

http://www.preventionpays.org/BillingInfo-PDFs/BillingInfo-WomensScreening.pdf

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036868.hcsp?dDocName=bok1_036868

These are time based codes. Medicare will not pay these codes.

If I were you I would determine the type of insurance the patient has. Once you figure out which payer would be processing the claim, look on there website to see if they have a preventative care listing, this should identify the requirements and recommendations issued by the Affordable Care Act (healthcare reform).

Here is an example:

https://www.bcbsal.org/providers/hcreform/hcrpreventivecoding.pdf

 

[ninaleeth@hotmail.com]

Use different diagnosis instead of preventive E & M

I would not recommend using a preventive E & M. Generally, the patient's primary care physician is utilizing those codes and the patient is only entitled to one of those services during a specific time period. If you use their preventive health visit, when they go for their well woman exam it will be denied. The patient is not going to be happy. It also is not really descriptive of the services you are providing, since your physician is probably not reviewing all body systems, doing a complete physical, etc.

A more accurate way to charge for your services would be to utilize the medical E & M codes such as regular office visits, but correct your diagnoses, Instead of using the Family History of cancer diagnosis as primary, I would recommend using the Special Screening for malignant neoplasm primary, with the family history as secondary. For example, if you are screening for Colon Cancer:

Dx 1: V76.51 Special Screening for malignant neoplasm of the colon
Dx 2: V16.0 Family History of malignant neoplasm of the GI tract

 

[jbrandt]

Thanks very much for the info, it's appreciated!

 

[mitchellde]

I would not recommend using a preventive E & M. Generally, the patient's primary care physician is utilizing those codes and the patient is only entitled to one of those services during a specific time period. If you use their preventive health visit, when they go for their well woman exam it will be denied. The patient is not going to be happy. It also is not really descriptive of the services you are providing, since your physician is probably not reviewing all body systems, doing a complete physical, etc.

A more accurate way to charge for your services would be to utilize the medical E & M codes such as regular office visits, but correct your diagnoses, Instead of using the Family History of cancer diagnosis as primary, I would recommend using the Special Screening for malignant neoplasm primary, with the family history as secondary. For example, if you are screening for Colon Cancer:

Dx 1: V76.51 Special Screening for malignant neoplasm of the colon
Dx 2: V16.0 Family History of malignant neoplasm of the GI tract

However if you are not performing a screening test/exam at that encounter it is inappropriate to use a screening diagnosis code. If the patient has had cancer and is here for a follow up after treatment then use a follow up code. You did not state the reason for the encounter and that will dictate the type of encounter it is.