Wiki Preventive + E/M

Create Wiki
M

mgshosted

New
Messages
2
Location
Elmo, UT
Best answers
0
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?
 
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.
 
Pam Warren said:
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.
Click to expand...
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.
 
mgshosted said:
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?
Click to expand...
Found this on: https://www.cms.gov/newsroom/fact-s...25-medicare-physician-fee-schedule-final-rule
Office/Outpatient (O/O) Evaluation and Management (E/M) Visits

For CY 2025, we are finalizing our proposal to allow payment of the O/O E/M visit complexity add-on code, Healthcare Common Procedure Coding System (HCPCS) code G2211, when the O/O E/M base code — Current Procedural Terminology (CPT) codes 99202-99205, 99211-99215 — is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service, including the Initial Preventive Physical Examination (IPPE), furnished in the office or outpatient setting.
 
Your billing service is buggin'. How would they justify a 25 modifier? How does the parent know they have hearing loss if the PCP did not do a hearing exam and the documentation shows no issues? Do they get a separate office visit just for giving a referral to an audiologist or ENT? Scary. If they crossed out everything that was done as part of the preventive, what would be left? Nothing.

Reference examples:
www.ama-assn.org

Can physicians bill for both preventive and E/M services in the same visit?

This regulatory myth examines if physicians should bill for both preventive/wellness and evaluation and management (E/M) services when they are performed during the same visit.
www.ama-assn.org www.ama-assn.org

It would be a totally different scenario if the patient came in and the provider did a totally separate workup for the ear(s) and found an issue, gave an Rx, did a separate exam, and then also gave a referral, etc.
 
You must log in or register to reply here.
Top