Wiki Preventative or E/M

[jacwea2782]

An established patient came to see one of our providers for her routine physical exam. The doctor covered patient's existing conditions and some other concerns that she had (elevated BP and nausea). The doctor spent 70 minutes of face to face time with the patient. He billed this as a 99215 with the code 99354 for prolonged services. The patient is upset because she feels this should have been billed with a preventative code. I'm really unsure what the correct answer is. I suggested possibly using a preventative code with an additional E/M code for the new problems. Any suggestion would be appreciated. Thank you!

 

[mitchellde]

If the patient voiced a complaint at the same time as a scheduled preventive exam you can under ICD-9 code for both the preventive E&M as well as an OV with a 25 modifier, however the documentation must support two separate visits, one which is preventive and one for the patient,s expressed complaints. This will not be allowed with ICD-10. OR you can bill one ov level based on the complete visit note but if the primary reason for the visit is preventive then you attach a 33 modifier to the visit level. So if the documentation supports using a 99215 with a 99354 then you append the 33 modifier to the 99215. Attach the V70 as the first listed dx code with the code for the problem secondary and link them all to the visit level.

 

[MikeEnos]

An established patient came to see one of our providers for her routine physical exam. The doctor covered patient's existing conditions and some other concerns that she had (elevated BP and nausea). The doctor spent 70 minutes of face to face time with the patient. He billed this as a 99215 with the code 99354 for prolonged services. The patient is upset because she feels this should have been billed with a preventative code. I'm really unsure what the correct answer is. I suggested possibly using a preventative code with an additional E/M code for the new problems. Any suggestion would be appreciated. Thank you!

Without seeing the note, and only based on the first few sentences here, I have serious concerns that this was billed incorrectly. The doctor spent 70 minutes face to face with the patient.... how much of it was related to the routine physical exam the patient came in for? Why was a preventive exam not billed?

Not every patient who comes in for a preventive exam is going to be 100% healthy. If a patient has multiple chronic problems that require significant additional workup, then you should bill a Routine Preventive Exam code plus an E/M code with modifier -25, NOT an E/M code with prolonged services. I'm guessing your office billed for prolonged services (which pay at a much higher rate) when in reality a good chunk of that time was spent furnishing the preventive exam.