Wiki Education- Preventative visit vs. a Sick visit

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LKaf7

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Hi!

Does anyone have any tips or tools on educating a provider when to use a LOS (Ex 99213) vs Preventative (99395)? I have given guidelines, examples, all the tips I can think of and this is still an issue. Example, DXs listed are all problem oriented but the CPT is preventative 99395, when I request to change to a LOS, I am asked "why?" when I explain this is a sick visit and not a preventative visit, they still don't understand. Any tips would be appreciated!

Thank you!
 
I am a provider trainer and have encountered this exact thing. I tell them this:

"A patient is scheduled to come in for a preventative visit. Possibly a check-up, a yearly exam, etc. Then suddenly they say 'Oh! By the way...' and go into issues they have. For example a back ache, or cold symptoms. If these issues are addressed and examined, then the visit becomes a "sick visit" and cannot be billed as a preventative visit. The coding will show symptoms or possibly a diagnosis for an issue. If you did any kind of workup for these, i.e. giving prescriptions, placing orders, etc., then they are no longer there for a preventative visit as your codes and notes will reflect that you actually have taken care of an issue that was presented by the patient. If the patient mentions the issues but no workup for the issues is done, then you can still bill for a preventative. The key here is ADDRESSING THE ISSUES. If they do, then it is a sick visit."

You must let the doctors know that it is their responsibility to inform the patient that if they weren't charged a copay for a preventative, that they may now be charged one from their insurance because this has become a visit where they have taken care of presenting problems, beyond preventative care.
 
Thank you so much for the feedback! A lot of time it's not even a preventative visit that was the pt is coming in for, they are coming in with some sort of issue to address, but some of the providers still use the preventative CPT, and I can't figure out why. Thanks again!
 
Preventative visit vs sick vist

Do you have any guidelines to education the providers?

Thank you,
Debbie Lamb, CPC
 
The coding position I am in is new to our practice, and I am the first to have it, so we are still developing workflows as well as guidelines. Right now, in my position, we have edits set up in our EMR system, if a claim hits one of our edits due to a coding issue, I then review it, and send a message to the provider with suggestions on changes. I do give guidelines and education as to why I am asking for these changes. I also supply information and education every 2-3 months on any sort of coding issue we have among all the providers, (EX: coding new vs. established incorrectly).
 
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