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Can anyone tell me from experience, if I bill a wellness code 99396 with an E/M 99214 (with mod. 25) will the insurance companies pay for just the E/M or both. I'd rather get paid for the wellness if any. I know BC pays for both but any idea about Regence/Medicare? Any help is appriciated...Ty in advance
 
Medicare does not cover the preventive codes 99381-99397. They will reimburse a medically-necessary office visit. Our contractor further requires that we adjust the difference between the 99214 and 99396, so that the patient has less responsibility for the non-covered service.

Most commercial payers will cover one or the other, but not both at the same time. The trick is to be able to support a significant, separately identifiable visit in addition to the PE. Chronic care and simple acute care does not constitute 'significant' or 'separately identifiable', so it's difficult to do.
 
If we see a patient for their annual wellness and they also have an issue outside the wellness and the documentation supports it we will bill the preventative with the appropriate E/M code with the 25 modifier. We have been reimbursed for both on many occasions. If we get a denial we will resubmit with notes and that usually takes care of it.
 
Tbeechler said:
If we see a patient for their annual wellness and they also have an issue outside the wellness and the documentation supports it we will bill the preventative with the appropriate E/M code with the 25 modifier. We have been reimbursed for both on many occasions. If we get a denial we will resubmit with notes and that usually takes care of it.
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How do your patients feel about getting a bill for a co-payment when they came in for their "free" annual wellness visit? Do you have a process for letting them know that you're actually billing two visits on the same day? What is the patient response?

I'm wondering, because patient satisfaction scores have impacted our policy with regards to a sick and a well visit on the same day. Although it makes sense from a convenience perspective, and definitely from a revenue perspective, our patient satisfaction scores trump both of those.
 
Pam, I'd like to answer your question. My husband's physician bills an E/M every time my husband goes in for his annual physical (he has depression and non-esstential tremors). Every time we request the notes and I review them there is never enough documentation to support the office visit. Basically he notes depression stable, tremors still present and renews the prescriptions.

How do we feel about this? Personally it makes me angry. The physician is not doing anything outside or over and above what he would do for the physical but trying to make more money. One year he was charged for an ECG when all the doc did was re-read his previous one. It also makes me think, if I know what's required, how many people who don't know is he doing this with? I feel that unless the patient's "other problems" take a significant amount of time (and stable chorinc problems shouldn't) then there is no reason to bill an E/M with an annual wellness visit.

I realize that payments are being reduced and the physicians need to find revenue to stay in business, but as you stated, there is the issue of patient satisfaction. I've told my husband to find a new doctor, but he likes this one so he won't switch so every year I have my fight with the billing dept. I would have left the practice a long time ago.
 
dclark7 said:
Pam, I'd like to answer your question. My husband's physician bills an E/M every time my husband goes in for his annual physical (he has depression and non-esstential tremors). Every time we request the notes and I review them there is never enough documentation to support the office visit. Basically he notes depression stable, tremors still present and renews the prescriptions.

How do we feel about this? Personally it makes me angry. The physician is not doing anything outside or over and above what he would do for the physical but trying to make more money. One year he was charged for an ECG when all the doc did was re-read his previous one. It also makes me think, if I know what's required, how many people who don't know is he doing this with? I feel that unless the patient's "other problems" take a significant amount of time (and stable chorinc problems shouldn't) then there is no reason to bill an E/M with an annual wellness visit.

I realize that payments are being reduced and the physicians need to find revenue to stay in business, but as you stated, there is the issue of patient satisfaction. I've told my husband to find a new doctor, but he likes this one so he won't switch so every year I have my fight with the billing dept. I would have left the practice a long time ago.
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If he is being "charged for an ECG when all the doc did was re-read his previous one", should you challenge that with the insurance company? Then then insurance company could request office notes for that date of service and determine that he was charged in error. Perhaps that might be more effective than calling the physician's billing office as they either do not understand correct coding or could be committing fraud. It concerns me, not only as a CPC, but also as a patient, that people are being charged for services not rendered. These are the types of things that are driving up the cost of health care.

I hope I'm not speaking out of turn here, but I think perhaps you should persue this type of billing further up the chain so someone can thoroughly look into this.

I hope this helps.
 
I called the insurance company to challenge the bill, after their "investigation" (which consisted of them reviewing the claim not an audit of the record), they conluded that the claim was paid properly according to their guidelines. When I pointed out that I had requested they audit the office notes I was told that they had reviewed the claim as it was filed and that it was filed appropriately and paid properly (actually it was applied to my deductible). I was then told that I had to contact the office to discuss any adjustments. I told them that if the E/M and ECG were adjusted off that I would be given credit on my deductible that I didn't pay, the CSR didn't sem at all concerned.

My point was that patients don't like paying for an office visit when they're supposed to be getting an routine physical, and that in (probably) in many cases it isn't justified because extra work was not performed.
 
Doreen, you're right on when you say that additional problems must take up significant time....which means that part of the routine well check includes management of the patient's usual chronic issues. Somewhere along the line, physicians and coders have gotten it into their heads that anything that's not "preventive" warrants an additional charge. It is wrong to encourage providers to fleece patients for either extra revenue or physician convenience when all they've done is write a script or ask about the patient's diabetes. Healthcare is being scrutinized these days as it is, without adding fuel to the fire. Good for you for bringing it to your insurance company's attention...but I bet they don't even know the coding guidelines, and deemed it "OK" simply because the modifier was appended. No wonder insurance premiums continue to soar.

Teresa, you're not the least bit out of line. As professional coders, it's our responsibility to make sure we do the right thing, and encourage our colleagues to do the same.
 
what I love about ICD-10 CM is that it will prevent this from happening anymore. Look closely at the well visit codes,
Z00.0- , Z00.1- , and Z01.4-
the all state general exam without complaint,suspected,or reported diagnosis.
you will not be able to append the additional dx codes to support a visit due to the chronic issues as they are the reported dx codes. Also each category contains an exclusion to not be reported with signs and symptoms, that you would code the symptoms instead.
and each category gives you 2 choices for with abnormal finding and one for without abnormal finding.
You should start preparing your patients and providers for this now.
 
We do charge the preventive and e/m in the same visit. We have the patient sign a form that states there may be the extra e/m and if the insurance co applies this to copay/ded, it is their responsibility. I do have to verbally explain this to the patients quite often also. I explain it in a way that says you come in for the well visit, but you have shoulder pain or a persistant cough that is discussed and treated. Also, if there is a chroinic condition that the treatment is changed or a referral to another provider is necessary. This could kick in the e/m visit. It is just like coming in today for the well visit only and coming back next week for the other issues. Our patients usually understand it when I explain it that way and are fine with it.
 
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