Hi all,
I have a similar situation that I am seeking help on....I have been trying to locate documentation from the Medicare website regarding split billing wellness and illness, and really what their official guidelines are. We have some controversy on the subject within our facility and administration is trying to push a policy on us that I don't feel comfortable following, hence I am searching for documentation basically to prove that they are incorrect in asking us not to split bill medicare patients and in the event they come in for a wellness and an illness is addressed we are to code only an illness visit that day. Here is what is says word for word....do any of you disagree with this?
In accordance from guidance we have received from the IMA, Brown's Consulting, Noridian Medicare and Karen Newton, Provider Educator for Noridian Medicare we are establishing the following guidelines.
WELLNESS/ILLNESS CODING
MEDICARE: If a patient is being followed for an ongoing condition ie; hypertension, diabetics or medication refills to treat an ongoing condition, this visit will be coded as an office call. If patient is receiving a female exam (Q0081-G0101) and meets the 7 out of 11 requirements, this can be billed in addition to the office call (99211-99215 est-99201-99205 new) with appropriate modifiers.
If a patient comes in for a wellness visit and a problem is found this also will be coded as an office call (exam) codes (99211-99215est 99201-99205 new).
Note: Medicare patient will not receive a split bill for wellness and illness (99381-99387 new-99391-99397 est).
If the patient comes in and is not being followed for a medical condition and no problems found then we code as a preventative service exam (99381-99387 new or 99391-99397 est). At this point the nurse or physician should inform the patient that this visit will be non covered by Medicare guidelines.
Medicare does not consider preventative visit as a covered service, therefore a GY modifier should be used stating we understand it is a statutory exclusion, not a medical necessity issue. Statutory exclusions do not require an ABN to be signed.
MEDICAID: If patient is treated for a wellness & an illness, the wellness visit is what should be coded if over 21 years of age. For patient under 21 years of age, we can split bill as per Medicaid guidelines. Sports physical can be coded as wellness at the wellness price as per Medicaid guidelines; we have established special charge codes for these.
COMMERICAL-SP: For commercial insurance we can bill split visits as described in the CPT book as well as from information from the IMA.
It is my understanding that when you are billing a medicare patient for an illness and a wellness on the same day that you have to deduct your illness charge from your wellness charge example:
99397 197.00
99213 63.00
total billed to patient would then be:
99213-25 for $63.00
99397 for $134.00
IS this correct and where on the medicare website can I find this?
Also I have a note that is similar...
here are my findings within it...
the patient was clearly in for a wellness exam, during this exam the Dr. performed a pap/pelvic, however he did not meet MCR guidelines on his pelvic exam with the criteria of 7 of 11 elements therefore I don't feel I can appropriately report the G0101 code, also the Dr. performs a joint injection to the shoulder (20610), if I try and carve out for the shoulder pain I would get a 99212, but he performed an injection for the shoulder pain therefore I was only going to code the 20610.....heres my dilemma, does the shoulder injection need to be reduced from the wellness exam?
here are my examples of prices and scenarios but not sure which one is correct and need to find MCR documentation to support my decision:
99397 reg price 197.00
G0101 reg price 35.00
Q0091 reg price 40.00
20610 reg price 70.00
should I go with:
20610 for 70.00
Q0091 for 40.00 (deducted from 99397 price)
99397-25 for 157.00
(G0101 not codeable due to lack of documentation therefore not deducted from the 99397)
OR:
20610 for 70.00 (deducted from the 99397 price)
Qoo91 for 40.00 ( deducted from the 99397 price)
99397-25 for 87.00
Thanks for all your help and if any of you have direct links to the Medicare website that explains coding regulations that would be great, also your input on the policy above would also be appreciated!
Thanks again
Ang, CPC