Wiki Routine & Level Exam On The Same Day

[rmortimore]

I am new to coding and our office has been having a problem getting payment when a patient comes in for their routine physical but then the Doctor ends up spending more time going over any number of issues that are not included in the routine exam.

I have been coding the routine normally but when I code the rest of the visit I put a modifier on it. Example being 99213-25. I was putting it with a dx code of why the doctor spent more time with the patient, but this is not getting paid. Now I have read in a couple of articles that the modifier 25 is correct but that you do not need to put a separate dx code with the level visit. Please someone help me with this. My office manager can't help me and as I said I am just starting out.

 

[Orthocoderpgu]

Some times you have to face reality

Just because correct coding allows you to provide a routine exam as well as address concerns brought up, does not mean that insurance companies realize this. Instead of fighting the insurance companies, have the patient come back to address the problems found during the routine exam. That way the insurance company cannot deny either. When a patient asks why they need to come back to address those issues, let them know that the insurance companies are not familiar with correct coding. When customers start complaining to the insurance companies, they will finally pay what they should but until then, it's best to avoid the situation. Just my two cents and I have had similar problems as well.

 

[kasullivan2]

Separate Coding

It is very difficult to pull out a 99213 in addition to a physical exam. The physical includes a complete exam and history. It is possible, however, you may want to make sure your visits truly are separate. The link below sums it up nicely:
https://depts.washington.edu/uwpsit...iancePolicies/codingGuidances/modifier25.html
If you are correctly coding and not getting paid, you should contact your provider relations person with the carrier with whom your physician is contracted. Make sure your diagnosis code matches the problem with the problem visit as well.
Some carriers may have policies on this and you should be familiar with the carriers and instruct the patients prior to the appointment whether or not the visit will likely be separately payable. The physician should also be educated on the issues.