Wiki Routine Exam vs Medical

Create Wiki
J

JLuz

Guest
Messages
25
Best answers
0
Patient makes appt for routine and comes in for routine exam and then the office manager is having us bill major medical insurance for a medical problem. Then finding out they also billed their vision plan for a routine as well on the same date. Office manager is insisting this is allowed but seems like double billing to me. I would appreciate some feedback!
Thanks!
 
http://www.aafp.org/fpm/2004/1000/p21.html

"According to CPT, separate, significant physician evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25. The key is recognizing when your extra work is “significant” and, therefore, additionally billable. CPT does not define “significant,” but asking yourself the following questions should lead you to the answer:

Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
Could the complaint or problem stand alone as a billable service?
Is there a different diagnosis for this portion of the visit?
If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
If your answers to these questions are yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as “A significant, separate E/M service was performed to evaluate … .”

The question you have to ask is: "When the RAC auditor comes knocking on my door, will my documentation support the additional billing?"

http://www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004955

The above website has an audit sheet for Eye exams, and this should help you.
 
but...

I am aware of using the -25 for multiple procedures, but my concern is more that the office is billing 2 different insurance companies. A vision plan as routine but also the medical insurance for a 'medical' reason. A couple patients have called saying the doctor didnt even tell then they has anything wrong. We are in a seperate location and I dont see his documention, nor am I responsible for it. But we have to field these calls from patients and it is concerning me. Again the office manager INSISTS that she can bill both insurances and I am wondering if there is any other eye dr office out there that is doing the same??
 
If the patient came in for a routine exam, then it cannot be billed to medical, some do this using dx codes for myopia and so forth when this is not a new finding. It sounds like you are correct and this needs to be stopped. If on the other hand the patient came in for the annual and also had a problem that could be billed to medical, then as long as there are two separate notes that do not duplicate each other at all ,one can go to eye and one can go to Medical.
 
thanks

thank you Debra! I will have to inquire as to how they are documenting these visits.
 
JLuz said:
Patient makes appt for routine and comes in for routine exam and then the office manager is having us bill major medical insurance for a medical problem. Then finding out they also billed their vision plan for a routine as well on the same date. Office manager is insisting this is allowed but seems like double billing to me. I would appreciate some feedback!
Thanks!
Click to expand...

I've always been taught it is one or the other, not both! The reason for the visit drives the level: In this case, the routine exam is the level.

From CPT Assistant Archive -
Coding for Ophthalmological Services
When should a physician report the general ophthalmologic services codes versus the Evaluation and Management ser*vices codes? It is important to note that there is no mandate that states that the ophthalmology codes must be used instead of the Evaluation and Management codes. As stated in the instructions for use of CPT, the physician should report the code(s) that most accurately identifies the service(s) or procedure(s) performed. It is important to note that the general ophthalmological service codes 92002, 92004, 92012, and 92014 are specific to the typical services rendered during an ophthalmological visit.
However, the code that most accurately identifies the ser*vice performed should be reported, whether it be an E&M service code or an ophthalmology visit code.

Dave Keown, OCS, CPC
 
Ann Marie Bianca, CPPM

I was under the impression that if a patient comes in for a routine eye exam and a medical condition was found, you cannot bill the visit to their medical plan. Claim must be sent to vision plan or if your office does not participate with vision insurance the patient will be responsible for the visit.
 
Routine Exam vs Medical. Key points

Some key points to keep in mind when you process these types of claims;
1. Determine which insurance the patient has. If they only have vision insurance then billing medical will be rejected. In some cases the medical insurances will cover both medical and vision make sure that the eligibility states the coverage information for each patient. Contact the insurances if they allow this type of visit and claim to be paid.
2. If the provider is billing both E&M and routine, audit the note to determine the amount of time was spent on each or which procedure carries the most weight for the visit for example if the provider bills a level four for both the routine and medical that would indicate that the provider spent more than usual time with the patient. Analyze the note carefully use the 95 or 97 E&M Guidelines. Usually within a routine visit the patient would present an issue or the provider may discover something during the exam. In most cases the medical with the routine or preventative would be a straight forward visit level 99201, 202 or 99211 or 212.
3. Make sure the diagnosis pointers are assigned to the correct codes. Some Practice Management /EHR systems will not place the pointers correctly, this will need to be manually entered.
Good Luck, Jeff
 
You are correct that you should not be billing both rt and medical. Billing two different insurances is double dipping! If they patient is there for a rt exam and the doc finds something medical, he can do testing too (there are some payers that are an exception).

Example: pt here for yearly exam but optic nerves make doc think the patient has glaucoma, so he does OCT testing and a refraction for a glasses rx.

We always ask for vision plan info and medical ins for cases like this. We use an eye code (92012/92014/92002/92004) with the med dx and the med dx on the OCT, with the rt dx code (myopia, etc.) on the refraction (92015).

We file everything to the medical insurance first, and they of course deny the refraction, then we send the rest to the vision insurance.

Obviously, though the medical necessity needs to be there for the medical testing. It's questionable when you say the patient doesn't remember the doc saying anything was wrong.
 
You must log in or register to reply here.
Top