Wiki Preventative and Addtional Complaint

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dballard2004

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I have a coding issue that I would like additional opinions on please. Per the CPT guidelines, if the patient presents for a preventative exam and during the course of the exam an abnormality is encountered or a preexisiting issue is addressed and the addtional problem requires addtional work to perform the key components of a problem-oriented E/M service, then you code the preventative code and the code for the addtional office visit with modifier 25 appended.

My question is this...the guidelines state "problem-oriented E/M service" is this interpreted to mean 99201 or 99212? If the addtional complaint was 99213 or higher, would you code it along with the preventative? I'm thinking that if the patient's addtional complaint is 99214, they would be too sick really for a wellness exam.
 
Can of worms..lol

You will probably get many different opinions about this but here is mine.

I see many situations in which a preventive is done along with a 99214.

Think about it. What does it take to hit a 99214? It is 2 of 3 and since you are doing a preventive service you can pretty much forget about getting credit for exam, how can you separate it out? So you are looking at history and mdm. You need a cc (earache), 4 HPI elements (left ear, 3 days, can't lay on that side, tylenol doesn't help) 2 ROS (runny nose but no fever), 1 PFSH (NKDA), and moderate mdm (OM -new problem 3 points, antibiotic- Rx management).

Does an ear infection stop you from doing a preventive visit? I wouldn't think so. Does it support a 4? It sure can if they document enough.

Just my opinion and how I look at it,

Laura, CPC, CPMA, CEMC
 
I agree. How "sick" a patient is doesn't determine the level of service. It's the documentation of the elements of the HPI, PE, and MDM that determine the level.
 
Preventive Medicine and E/M services

I work for a carrier whose policy states reporting preventive codes with E/M services should not be a common occurance. To justify the services, the rcords must have sufficient documentation regarding the appropriateness of performing both services and documentation that the key components have been met for the E/M service.

My questions are:
1. How would I carve out the respiratory exam for the E/M (bronchitis) if the lungs are normally reviewed for a Preventative? Does it matter, as there are no required number of organ systems for the Preventive Exam?
2. How to determine what is significant versus minor complaint if modifier 25 is used?
 
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We've typically billed out office visits with preventive services if the HPI and Assessment/Plan meet the documentation guidelines. (exclude exam, for obvious reasons). However, there should be 'significant additional work' performed in order to do this. For example, a follow up of single or multiple stable chronic conditions within the preventive visit doesn't necessarily meet 'significant additional work'. I'd recommend to only bill an additional E&M visit for a significant acute problem or when multiple chronic conditions warrant a great deal of extra work, such as multiple medication changes or additional investigative workup (not routine). We never code an additional E&M based on time; since there is no time criteria for a preventive exam to act as a benchmark.


Although CMS almost encourages us to bill both visits, (our carrier, NHIC has us adjust the amount of the Pe by the amount of the sick visit, which gives a break to Medicare recipients), other payers are not so generous, and often charge two copayments. As you can imagine, this is not a patient-friendly practice, and although we don't discourage the billing of two codes when clearly warranted, we don't encourage our physicians to bill out both services every time they do a preventive exam.
 
Pam Brooks said:
We've typically billed out office visits with preventive services if the HPI and Assessment/Plan meet the documentation guidelines. (exclude exam, for obvious reasons). However, there should be 'significant additional work' performed in order to do this. For example, a follow up of single or multiple stable chronic conditions within the preventive visit doesn't necessarily meet 'significant additional work'. I'd recommend to only bill an additional E&M visit for a significant acute problem or when multiple chronic conditions warrant a great deal of extra work, such as multiple medication changes or additional investigative workup (not routine). We never code an additional E&M based on time; since there is no time criteria for a preventive exam to act as a benchmark.


Although CMS almost encourages us to bill both visits, (our carrier, NHIC has us adjust the amount of the Pe by the amount of the sick visit, which gives a break to Medicare recipients), other payers are not so generous, and often charge two copayments. As you can imagine, this is not a patient-friendly practice, and although we don't discourage the billing of two codes when clearly warranted, we don't encourage our physicians to bill out both services every time they do a preventive exam.
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Thanks Pam! Anyone else have comments?
 
I agree with Pam. This should be rare. The documentation should really be "above and beyond" and support that extra time was spent. It almost never does with my docs. I go through their notes and highlight what would support the problem, and not be inclusive of the "well" visit, and usually come up with only a few sentences....definitely not the hx, exam and mdm needed for an ov.
 
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