Wiki Ekg, chest x-ray with preventative visit

[jrush7779]

hello,

We have been experiencing problems with UHC paying EKG's and Chest X-rays as a part of the patient's annual physical. UHC tells the pt we should have coded as "preventative" and leads the pt to believe there is some new codes for a preventative EKG and Chest :X-ray.

We bill CPE as ...
example
DX Code v70.0
99396
93000
36415
71010

Some pt's have additional dx's such as 401.9, 272.2, v58.69 also.
UHC either puts the cost of the ekg , CXR to the pt's deductible or flat out deny.
Can anyone provide any insight on this?

 

[jackson7591]

Reference

https://www.oxhp.com/secure/policy/preventive_medicine_screening_codes_111.html

Is there sufficient documentation to demonstrate s significant and separate medically necessary E/M service at the same time as the preventative service? Was the EKG and or chest x-ray associated with the E/M service? Did the provider document additional diagnoses for the E/M service and associated procedures?

 

[jrush7779]

Hi,

Yes, there is significant documentation and only sometimes are there add'l dx codes if the pt has any underlying dx.

In our practice, they have always done a "complete" physical with EKG, Chest X-ray, Urinalysis, and Blood work are a part of the pt's annual physical. Insurance companies have always paid these procedures with the preventative visits with no problem. Now, we have UHC putting the allowable of these procedures to the pt's deductible and sometimes denying them completely. We billed these procedures sometimes with v70.0 as the only diagnosis and sometimes with add'l diagnoses based on the pt's medical hx.

Just trying to see why now they have started doing this and have always paid in the past.

 

[jackson7591]

Mod 25

There has been a significant push by carriers regarding mod 25. They acknowledge that mod 25 may be appropriate. However, as always, documentation and medical necessity must be met. As such it seems that not every patient in for a yearly physical "needs" an EKG and/or chest x-ray, which is logical.

We have been remindng our providers to clearly document their rationale for tests and procedures during any office visit, including annual visits. Does the pt have some personal, social , and/or family history/risk factor which meets the medical necessity threshold for an EKG or chest x-ray? Or any other test or procedure? If so document it clearly. If it isnt clearly documented, then the carriers are entitled to question why it was done.