Wiki Preventive + separate E/M

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nc_coder

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I would love to know the percentage other Family Practitioners are using a Preventive visit and a separate E/M on the same day. Our lead physician uses this on almost every physical that comes through the door. He has started having me hold all physicals the other providers in our practice perform until he can review them because he feels they are under using this way of coding. I, personally, feel he is overusing it. I am just curious to see how others are doing this.
I completely agree with the situation of a physical and then a patient has a sinus infection (just an example). However, he is coding a separate E/M for chronic conditions such as HTN when no changes in treatment are made. He feels the discussion of the chronic condition is "above and beyond" routine services.
 
honestly only the patient can request what amount of healthcare they get. Meaning without the patient having a symptomatic complaint then there is no basis for an office visit. Part of the expectation of an annual preventive visit is that chronic issues will be addressed. The provider cannot decide to add an office visit when it was not requested by the patient. Also the affordable care act states that when the reason for the visit is primarily preventive then you cannot charge the patient for co-pays or deductibles. therefore there is no way to charge a separate office visit. If the patient presents for an annual and has a complaint then it is not primarily preventive.
I know if go back several years there was a transmittal regarding the 25 modifier and preventive visits which stated that the patient had to utter a symptomatic complaint before you could charge the office visit with a 25 modifier.
 
Thank you for that. That makes perfect sense to me. I would love to have substantial evidence from a reliable source on the subject to back me up when I fight this. I know the modifier 25 is a "hot topic" for the OIG right now.
 
Debra has hit the nail on the head.

I guess the difficulty for some physicians is that a patient when making the appointment will surely indicate they are coming in for their annual physical, but when they get to the office they may bring up a recent medical issue: well the physician now has to change gears and make the determination: Is this a sick visit, I now need to collect a copay?????

The physician still has to make the determination (with proof) as to whether this complaint requires a change in his treatment of the patient. Certainly the discussion of a chronic condition won't necessarily result in the use of the 25 Mod, their has to something significantly different in the care of the patient.

Unfortunately this dilemma is more common than you think.......
 
This has been a battle I have been fighting since I started working here. And, unfortunately, when the doctor insists on coding the exams this way, I am the one that has to try to justify it to the patient when they call to find out why they are left responsible for a copay or deductible. The issue has just started intensifying lately with the head physician calling the other providers out on not using the code as often. Our NP worded it perfectly yesterday when she said she felt like it was "overkill".
Will the new annual exam ICD10 codes make this situation null and void? Since there a dx code for normal annual exam and a code for annual exam with abnormal findings, will they even be allowed to bill the separate E/M?
 
I just wanted to update this thread. I am no longer working for this physician. He demanded I do things his way even with all of the research I brought him to show he was using it incorrectly. Bottom line to all coders... if you know what you are doing is correct and have credible information to back you up, don't compromise your expertise. Integrity is everything.
 
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