Wiki Is reviewing Preventive Care lab results considered a Significant, Separately Identifiable service?

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kvr2112@yahoo.com

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The patient comes for a Preventive Exam (cpt 99396). In his note, the provider includes a status of the patient's chronic conditions based on his review of the lab work done one week prior, e.g. Hypertension, stable with meds; Diabetes, stable with meds. He then adds CPT 99214 to the 99396 as a Significant, Separately Identifiable service with a 25 modifier. Then the claim comes to me for coding review and I'm not sure that the" Significant, Separately Identifiable" qualification is actually met. Opinions?
 
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Is he the one who ordered the labs? Is someone else treating those conditions? Are these normal preventive labs the insurance company includes in their preventive services?
 
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Cls1530 said:
Is he the one who ordered the labs? Is someone else treating those conditions? Are these normal preventive labs the insurance company includes in their preventive services?
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He is the one treating the chronic conditions. The labs ordered to check on these chronic conditions are not considered Preventive, however there are no abnormal findings to address, e.g. adjust meds.
 
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kvr2112@yahoo.com said:
The patient comes for a Preventive Exam (cpt 99396). In his note, the provider includes a status of the patient's chronic conditions based on his review of the lab work done one week prior, e.g. Hypertension, stable with meds; Diabetes, stable with meds. He then adds CPT 99214 to the 99396 as a Significant, Separately Identifiable service with a 25 modifier. Then the claim comes to me for coding review and I'm not sure that the" Significant, Separately Identifiable" qualification is actually met. Opinions?
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The question is whether the chronic conditions were evaluated and managed at the visit and if that was work was significantly beyond that of the preventive service. Is there sufficient documentation to support that the conditions were managed separately from the preventive service? Does the portion of the note addressing the chronic conditions look similar to what would be documented for an encounter that occurred on a date when no preventive service was rendered? It is not necessary for the problems to be unstable or for there to be a change in medications (unless the specific payer requires this to count prescription drug management as moderate risk). Reviewing the laboratory tests that were likely ordered at a prior visit for follow-up of the chronic conditions by itself is not an E/M service but making decisions on continued management is distinct from the preventive service.
 
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