Wiki How would you code this visit?

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mrolf

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How would you code this visit? Patient comes in for annual follow-up of her medical problems and to have her medications refilled.

Another example is: Patient comes in for her yearly evaluation of hyperlipidemia, HTN, and DM II.

I have been coding this as a problem visit. I hope that is correct. Any opinions on this??? Thanks.
 
I would not code a problem visit as these are documented as annual yearly, This is what the prevent E&M codes are for using the V70.0 as the primary dx.
 
The above examples that I have given are specific to Medicare patients that are coming into see the doctor to renew their medications for their chronic conditions. This is the reason why we are billing the problem exams. How would you recommend the doctor state the reason for this visit?
 
It still sounds like the annual wellness exam which is preventive and if Medicare does not reimburse then the patient is responsible. I do not agree with coding it as a problem encounter when no problem is present just to get Medicare to pay the claim.
 
correct

Yes, you are billing this correctly if they are coming in to see the Dr. for their present illness/condition.
 
I agree...

There is a decent sized list of what constitutes a yearly exam (routine PE), not the least of which is a comprehensive multi-system examination. I would say since this is a multi-problem visit with med management, that an E/M is perfectly acceptable. I just wouldn't mention the phrase "yearly exam" that someone could misinterpret to mean "routine physical examination". I work for a cardiology group where patients are seen in "annual" follow-up and we NEVER do a physical. It just happens to be the frequency the patients need to be seen.
 
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The problem I have with coding this as a problem encounter is that the patient, from your description, is asymptomatic and has no acute issue. An annual wellness exam is exactly that to evaluate the wellness and go over the existing issues and check medications. It should not matter the type of insurance only the reason for the encounter. Now take into account the patient's statistics, if we do not indicate that they accessed healthcare for preventive wellness it could adversely affect their benefits. I have patients that have as a benefit, that if they have a wellnss encounter once a year, even though they must pay out of pocket for it, their premiums the next year will go down. If we do not code this as a preventive encounter, then we will be denying the patient access to this benefit.
 
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Flip side

Under Preventive Medicine Services header in CPT it states: "If an abnormality is encountered or a preexisting problem is addressed in the process of performing an preventive medicine E/M service AND if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M, the the appropriate office/outpatient code 99201-99215 should be added..."

By that definition, the AMA is defining a non-preventive E/M as something that requires additional work to perform history, exam, and/or MDM. Take the "in addition to language" away because its not relevant to the point, but it does define the problem-oriented E/M.

Additionally, Medicare covers services based on "reasonable and medically necessary" criteria of which one could easily argue an annual review of medication is exactly that. And in the example you gave, wouldn't your doctor perhaps do a foot exam because the patient is diabetic or order a lipid panel to evaluate the hyperlipidemia? If so, I'd say that certainly qualifies as "additional work" for MDM and meets the above criteria.

This is a judgment call, but either answer is arguable.

Best of luck!
 
I could go either way on this one, I would just make sure that if you are charging for a physical that the documentation is there. Physicals require documentation going far beyond just an annual check up for 3 specific conditions, it should include a multi-system exam as well as a full review of systems.
 
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