Wiki Preventive & E/M on Same Day

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We are having some challenges with billing for sick and well visits on the same day, as allowed by CPT. (Particularly for Medicare patients understanding their responsibility for paying Preventive Visit) (e.g., patients come in for an annual check-up, but have problems that need to be addressed, as well.)

Do your physicians bill for both the well visit and the sick visit; bill for a sick visit only; bill for a well visit and ask patients to return if management of condition can be deferred until later?

If you do bill for both a well and sick visit, is this your practice for New Patients and Established?

If both a sick and well visit will be charged, do you inform the patient that they will be getting two charges? If so is the information given verbally, in writing?

How are you instructing your physicians/providers to document – two separate notes?

Any help you can give would be most appreciated.
 
First of alll, specifically for Medicare, if you code both a problem oriented visit and a preventive, you MUST carve out the fee. For example, if your fee for 99397 is $200 and your fee for 99213 is $100, then you must subtract 99213 from 99397 so that the total charge is no higher than your fee for 99397. Therefore, your patient is only responsible for $100 for 99397.

The preferred method is two separate notes, but a good auditor will be able to pull the problem oriented from the preventive.
 
Lisa Curtis said:
First of alll, specifically for Medicare, if you code both a problem oriented visit and a preventive, you MUST carve out the fee. For example, if your fee for 99397 is $200 and your fee for 99213 is $100, then you must subtract 99213 from 99397 so that the total charge is no higher than your fee for 99397. Therefore, your patient is only responsible for $100 for 99397.

The preferred method is two separate notes, but a good auditor will be able to pull the problem oriented from the preventive.
Click to expand...

Actually CMS recommends the "allowed amount" of a sick visit be carved out, not the fee schedule amount. I've asked this question a number of times, and the answer from CMS is "allowed amount" be subtracted from the preventive amount. Remember, you may also carve out a breast/pelvic G0101 code, as well as the Q0091, obtaining & handling pap, if performed. There are documentation requirements for these, so be careful. Good luck!
 
Medicare and the crave out is not a question the guidelines are published and clear and those are being followed when we bill both. However, it's the other questions we are looking for answers on.
 
efrohna said:
Actually CMS recommends the "allowed amount" of a sick visit be carved out, not the fee schedule amount. I've asked this question a number of times, and the answer from CMS is "allowed amount" be subtracted from the preventive amount. Remember, you may also carve out a breast/pelvic G0101 code, as well as the Q0091, obtaining & handling pap, if performed. There are documentation requirements for these, so be careful. Good luck!
Click to expand...

You are correct. I should have stated "allowed" amount.
 
We are having some challenges with billing for sick and well visits on the same day, as allowed by CPT. (Particularly for Medicare patients understanding their responsibility for paying Preventive Visit) (e.g., patients come in for an annual check-up, but have problems that need to be addressed, as well.)

Do your physicians bill for both the well visit and the sick visit; bill for a sick visit only; bill for a well visit and ask patients to return if management of condition can be deferred until later? We bill for both, although I do not see a lot of it happening.

If you do bill for both a well and sick visit, is this your practice for New Patients and Established? That depends on the situation, but typically these are established patients. We would bill for new if the requirements are met.

If both a sick and well visit will be charged, do you inform the patient that they will be getting two charges? If so is the information given verbally, in writing? Not that I am aware of, it seems that a lot of Medicare patients are not aware that well visits are not covered in the first place, as we frequently get calls regarding the charges for these even when no sick visit is charged at the same time. So since the prevent is reduced by the sick visit charge, it helps make it easier to swallow (even though the allowed charge for the sick visit doesn't reduce it by much).

How are you instructing your physicians/providers to document – two separate notes? Our providers use one note, we just audit them and carve out.

As I said I do not see a lot of this happening. Typically most Medicare patients have 3 chronics that are being addressed (at least in our area) at their visits, so the "well" visit doesn't apply in their case. It seems it is quite unusual to have a Medicare patient with no health issues.

I hope this helps.
 
Cheryl Driver said:
Medicare and the crave out is not a question the guidelines are published and clear and those are being followed when we bill both. However, it's the other questions we are looking for answers on.
Click to expand...

Cheryl,

Can you tell me where the guidelines are published on the CMS website or maybe give me the link? I need to provide someone with the source for this guidance.

Thanks!
Janice
 
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