When billing for a Preventive Medicine visit and an E & M visit where the criteria is met for both to be billed, if the Preventive Medicine code that is used is for a new patient, is the office visit E & M also billed with a new patient code? Thanks.
The rationale used with many payers is, they're only new once. The CPT instructions are very confusing in their reference to 99201 - 99215 (implying that you can use a new P/O E/M w/a new preventive E/M) - I wish they would change that verbiage, honestly. The payer's rationale makes sense -
With a problem and preventive E/M at the same time, the preventive E/M is considered the more comprehensive procedure; you have to go above and beyond it to bill a problem-oriented E/M on the same DOS, (which is also why the P/O E/M requires the 25 modifier, and not the preventive service.)
So, technically speaking, the preventive E/M comes "first" for claim processing. Once that charge has been considered, the patient has officially received a 'professional service' from the provider, thus meeting the definition of an established patient for the purposes of choosing the problem E/M.
That logic's not perfect, but it fits with the guidelines for new/estb. patients better than the guideline in the book, and as Rebecca mentioned, that's usually how payers view it. It wouldn't be any different if both visits occurred at once, or if the patient had a well check in the morning and came back that afternoon with a problem. I actually had a pretty big debate with a clinic manager over this issue, because they didn't agree with the denial based on CPT guidelines - it's hard to explain that neither side is technically 'wrong' - both interpretations of the guidelines work, but commercial payers have the discretion to interpret the rules as they please, so they'll get the final word in the matter. Most have policies about this somewhere in their disclosure notices/coverage guidelines, so check out their website to see if you can find it.
This isn't an issue I'd bother trying to appeal, if I were you - it's not worth the trouble to get a few extra bucks added to the 50% of the allowable reimbursement you're going to get for the second E/M, anyways. Hope that helps!
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