You cannot bill a sick visit with a wellness visit! The exclude 1 note is very clear clear on this and the definition of exclude 1 is very clear. You are instructed to code to signs and symptoms. This is not a payer issue this is ICD-10 CM! Please tell me how it is that you feel you can still bill both when clearly the codes state that you cannot.You can bill both the sick visit and the physical exam on the same claim.
Things to keep in mind when doing this.
- Is the provider still able to establish a baseline with the pt's illness?
- If so, use a low level EM code, add a modifier 25 to the EM code
- Be sure to designate the correct ICD-10 codes to the EM and the preventative visit.
- Suggest to your provider to document the physical and the EM separately, in case documentation is requested by the insurance carrier
Hope this helps
My email clearly asked if I would choose abnormal findings for an ear infection.
I totally understand what the book says and if you're just trying to educate someone to pass a certification exam, I get it. This is not going to fly in real world coding, specifically for me in a pediatricians office. And yes, there are payer specific guidelines that we follow in accordance with our contract with an insurance company. I guess kind of like how you're saying the ACA apparently overrides CPT guidelines. I do believe this will be addressed.
Yes you can bill both. The modifier 25 needs to be appended to the Preventative CPT code not the E/M sick CPT ( 99212-99215) as far as ICD 10 linking you cannot link the same codes for each as the appended E/M is a " by the way" scenario and insurance will reject . So if the preventative dealt with 4 DX link those only .. The sick visit will have seperate DX linked. As long as the physician can justify that E/M level with time and DX they will pay. I have a 100% success rate before and after ICD 10 transition . Make sure your physician knows the documentation requirements in case of audit . There should be two seperate notes.