Wiki Prev & E/M

[bluerose13us]

What is the proper way to bill new patient preventive (99385) with an E/M? Is the E/M considered new or established? Do both get modifier 25? Thanks for your help.

 

[MarcusM]

If reason for new patient visit is the preventive care, then 99385. Modifier 25 indicates that on the day of a procedure like a preventive care visit, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service. So in this case,
99385 Dx: V----- for new patient preventive check, then
Established patient 99213-25 for Dx: 462.-- or whatever illness.

 

[Saedron]

If reason for new patient visit is the preventive care, then 99385. Modifier 25 indicates that on the day of a procedure like a preventive care visit, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service. So in this case,
99385 Dx: V----- for new patient preventive check, then
Established patient 99213-25 for Dx: 462.-- or whatever illness.

I agree, and I dislike split billing! Be mindful that the E/M with the 25 modifier will trigger a copay for the patient if he or she has a copay. This is why I tend to avoid preventative coupled with an E/M same day. It's messy.

Also, I've read (I forget where) that some payers will reject an E/M greater than a level 2 with modifier 25 when coupled with a preventative code. Medicaid in my state will reject the claim if it's split billed. If the patient is sicker than a level 2 then they are not 'well' enough for a 'well' visit. The provider needs to adjust the visit to an E/M and schedule another visit for the preventative. Either way, the patient is charged one copay - same day or different days.

Hope that makes sense.