Wiki Preventive vs. E&M code

[JLuz]

I am reviewing some of my doctors billing. They are a PCP office, and I see they are billing all insurances 99386 & 99204-25 for the same dos. They were told by their billing office to bill this way. Medicare is only paying for one code of course, but Horizon has paid both on may claims. As far as I have ever learned there should only be one office visit code. I want to make sure I am correct in thinking that this is wrong before I start spending hours on the phone....any input would be appreciated

 

[Monika Liddle]

Preventive vs EM code

Per CPT EM Guidelines, Preventive Medicine Services

"If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key component of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be report. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. "

The key is going to be the providers documentation to support both codes. I have found the providers do not document enough to support the 99204.

 

[mitchellde]

to bill an OV with a preventive the patient must have a symptomatic complaint as well as the need for the annual, or the provider must note an abnormal finding necessitating a separate visit. You must assess the prevent and the visit elements separately and they cannot cover the same ground twice. Therefore to have a level 4 new patient as well as a preventive the patient will have been examine thoroughly as well as have a fairly detailed issue that requires separate evaluation. Many payers require that you have 2 separate office notes in the chart to show that a separate issue was addressed in addition to the preventive.

 

[JLuz]

She is a new doctor and not that busy yet, so she is spending quite a bit of time with her Medicare patients, but I am afraid that billing 50% of her new patients in this way is going to flag her for an audit. Is that a safe assumption? I have never worked for a doctor that even billed one visit this way, let alone 50% of them and I don't want to see her end up in trouble because someone told her she could. I understand the ability to do so based on the information you provided, but it would seem these would be few and far in between. Looking for some feedback -thanks!!

 

[MarcusM]

I used to manage a pediatric practice and we would see new patients for an illness. Usually, they were also behind on their vaccinations and Medicaid rules indicated we were required to "catch up" on vaccinations. We would bill new patient E&M with mod 25 and then preventive care codes. A year later the Mcaid HMO recouped all the new patient payments on the non preventive codes and paid at established patient codes. I appealed all with most excellent documentation that I required by the pediatrician and all claims were again paid correctly. It was a hassle, of course, and never would have been possible without "most excellent documentation" of new patient "sick" visit and preventive vaccinations with well child checkup.

 

[Herbie Lorona]

Medicare doesn't pay for 9938* or 9939* codes. A preventative and sick visit can be billed together if the documentation supports it but if it is a new patient you cant bill a 99386 and a 99204. One code has to be a new patient code and the other would be a established patient. When we have these type of visits we bill the preventative visit as new and the sick visit as established and we don't have an issue with getting payment on both for the most part!