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Lisa Bledsoe

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I have to laugh...I thought I finally had my senior medicine doctor "trained" to code preventive visits correctly even though Medicare does not (currently) cover them. And suddenly - she is coding 99214-25 with the chronic conditions (always stable) and G0101, and stating in her note "Patient wants GYN physical only" (she is doing breast and pelvic; no pap). Then goes on to document the stable chronic conditions and no changes, etc. So I sit here wondering what happened. Did the patients wear her down because Medicare doesn't pay for preventive and she got tired of them being upset about their bills? Or, have I missed the point? Any thoughts?
 
Medicare Preventive/problem oriented

Lisa,

I am not sure what you are asking but, I beleive the service was coded correctly. If the patient presented to the office for a follow up of chronic conditions and a breast/pelvic exam. It would be appropriate to bill an E/M with modifier 25 for the chronic conditions and the G0101 for the breast/pelvic exam.

Allison Wikcham, CPC, CEMC
Compliance Specialist
 
These patients are scheduling a physical, but she is documenting this way to get around the preventive issue. The intent of the visit (in my opinion) is a preventive visit, since all of the other problems are stable/no change in treatment; and these patients come in on a routine basis (ie monthly, every 2-3-4...months).
 
I have to agree with Lisa. The purpose of a preventive exam is to discuss any chronic but stable conditions. This does not make for an ov with a preventive in my opinion. This is why the charge for a preventive is so high. The fact that Medicare or other payers do not pay for a preventive is no reason to charge either an ov instead or an ov in addition just because chronic conditions and treatment plans were discussed. The patient may be responsible and that is the way it is. There are some benefit plans that have subtle benefits even the patient may be unaware of, such as lower preimums the next year just because the did have a preventive encounter, even though they had to pay out of pocket for the preventive.
 
Personally, I see this as a misrepresentation of the service. If the "intent" is a wellness exam, that's exactly how it should be coded. However, without sounding condescending, some physicians have become crafty with their documentation so that it can be difficult to decifer whether the patient's visit was for a problem oriented visit or indeed a wellness exam.
 
Rebecca - I agree completely. It is a "crafty" way to get around it. Do you have any suggestions on how I can clarify this with the physician without making it seem like I'm calling her on "borderline fraudulent" documentation and coding?
 
Even if she documents chronic issues as stable there is nothing symptomatic to base an ov on. You need a chief complaint for the ov or a reason such as followup from a procedure. It sounds like you have none of that. So the documentation does not support an additional ov it supports a preventive. I tell the physicians to think of a preventive as the same thing as a department store getting ready for a storewide sale, once a year they take a complete inventory where they open all the drawers and count items. Well once a year a patient comes to the office for their annual inventory which includes opening the patient's drawers (sorry!) and checking out the chronic conditions to get the patient ready for the next year. Nothing is an issue for the patient nothing is symptomatic, therefore no rationale for an ov. For routine followup due to medications, I use a V58.83 plus a V58.6x code to show this is an encounter for med management and the visit level will be rather low unless there is a lot of counseling about the medication along with time documentation.
 
Debra - I like your analogy regarding inventory! I hope you won't mind if I use that to discuss this issue with my physician. The actual statement under chief complaint is "gyn only physical exam. she requested a GYN only prev med ebal, then address her active concerns" (which are COPD/lung ca, htn, HRT for post menopause, seasonal allergies). This is just one of several I have stumbled upon. (I am the only coder employed for 65+ providers who do their own coding :eek: and I have to help the business office clean up the messes!)
 
I would, with the help of a manager, remind them that the OIG has recognized this as a form of "misrepresentation".

a. Coding and Billing.

A major part of any physician practice’s compliance program is the identification of risk areas associated with coding and billing. The following risk areas associated with billing have been among the most frequent subjects of investigations and audits by the OIG:

Billing for non-covered services as if covered;

http://oig.hhs.gov/authorities/docs/physician.pdf

I would also remind them that within their contract with Medicare, there is a clause that strictly prohibits this type of practice. When the provider signed their contract, they accepted the terms of the contract and the obligations that came along as a participating provider.

3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:

a) knowingly presents, or causes to be presented, to an officer or any employee of the United
States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; or
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid
 
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