Wiki Preventive + E/M

[mgshosted]

I've tried researching this but am still not clear on an answer. Family physician does a well child exam during which patient/parent mentions they have some hearing loss in one ear and would like a referral. Physical Exam shows no issues w/ ear (no hearing test done). Can physician bill the preventive exam and E/M? Where the exam of ear is part of the physical and there was little to no management wouldn't this full under the scope of the physical?

 

[Pam Warren]

Unless the additional work done with regards to the evaluation of the hearing loss is significant and can be separated from the documentation inherent in a typical well-child visit, the E&M wouldn't meet medical necessity. With an E&M you might require a separate medically appropriate history and exam (per the circumstance) but would need to show some sort of medical ddecision-making "Nothing's wrong" is certainly a decision, but is it significant enough to bill separately?

And when billing an E&M with a preventive exam (that has no patient cost-share), you'll surprise the parents with a bill for the office visit co-insurance and/or deductible. Unless the work done in evaluating the hearing loss was well over and above what the provider would do in any other Pe circumstance, it's best to just bill the Pe.

 

[mgshosted]

Unless the additional work done with regards to the evaluation of the hearing loss is significant and can be separated from the documentation inherent in a typical well-child visit, the E&M wouldn't meet medical necessity. With an E&M you might require a separate medically appropriate history and exam (per the circumstance) but would need to show some sort of medical ddecision-making "Nothing's wrong" is certainly a decision, but is it significant enough to bill separately?

And when billing an E&M with a preventive exam (that has no patient cost-share), you'll surprise the parents with a bill for the office visit co-insurance and/or deductible. Unless the work done in evaluating the hearing loss was well over and above what the provider would do in any other Pe circumstance, it's best to just bill the Pe.

My thoughts exactly. Our billing company was trying to add an E/M so I was trying to find some kind of clear documentation for a scenario like this.