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Preventive medicine and office visit, same day
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Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam

Let’s review what a preventive medicine service is, in order to answer that question.  Preventive medicine services are:

• The description given by CPT® for “annual physicals”

• Divided into new and established patient visits

• Categorized by the age of the patient

• Individually listed, with RVUs in chart in appendix

• 99381—99387 for new patient, preventive medicine, delineated by age

• 99391—99397 for established patient, preventive medicine, delineated by age

A preventive medicine service includes:

• Age/gender appropriate comprehensive history and physical exams

• Require anticipatory guidance and risk factor reduction

• Referral for/provision of screening tests and immunizations

• Include treatment of existing problems that “do not require significant extra work”

• Separate payment (per CPT) is allowed for vision, hearing and screening tests, although not all payers pay based on CPT® rules

• Typically, tympanometry is paid separately, but the vision screening (99173) may not be (Although it should be, per CPT

• Many visits have components of both preventive medicine services and “sick” visits

Bill a self pay patient or a commercially insured patient both a preventive medicine and office visit when:  (Medicare and Medicaid have their own rules, of course!)

  • The provider performed significant additional work and documented that work.  This could be for a new onset problem or deteriorated existing problems
  • The History of the Present Illness shows this extra work by describing the patient’s symptoms.  (He reports that for the last 4 weeks he has had increasing….made worse by….He relates the start to an episode….)  Or, document the patient’s chronic diseases (Her BP readings at home are not good, although she continues on….  We have checked her machine with ours in the office….  She also reports that her osteoarthritis is not in good control and the medication….  In the morning, especially…..)  Show the extra work.  “Patient with a history or XYZ is doing well at home” is not extra work.
  •  Assessment and plan shows management of these problems.  If the assessment and plan relates entirely to health maintenance (She refuses a colonoscopy but we gave her a flu shot today.  She’s scheduled for a mammogram and DEXA scan” that does not show the need for an office visit on the same day. “I sent her for STAT labs, xrays…”  “I adjusted her hypertension medicine and asked her to come back every week for the next few weeks to have it checked in our office.”

Can you get paid for both?

• Varies by insurance company

• A separate note helps you to select the level of service for the non-preventive medicine portion of the service

• A separate note shows the insurance company the significant extra work you performed—although it is not required by CPT

CPT® says: “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should be reported.  Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.  The appropriate preventive medicine service is additionally reported.”

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Charlene
Sat, Apr/11/2009
Ratings: •••••
Well Woman Exam Coding
There are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others will pay certain ones with a preventive visit (9938x-9939x series) and others will not. Some will only pay the HCPCS codes above with an Office Visit (9920x-9921x series) and others will not. Usually health plans are not forthright in communicating their reimbursement patterns and the provider will need to do their own research and billing trials based on health plan.

Billing the Q0091 and/or the G0101 with a Preventive Medicine code is somewhat controversial. You will find some people who are adamantly against it. I personally feel that because the Preventive Medicine codes are only differentiated by New and Established patient and by Age; therefore gender specific further evaluation should be reimbursed on top of the Preventive Medicine visit. So, basically, a female preventive medicine exam reimburses the same exact amount as a male of the same age. However, a well-woman exam is more labor intensive, greater risk and utilizes more supplies and time than what would be included in a well-man exam. Why shouldn't we receive a higher reimbursement to cover the costs of a breast and pelvic exam and obtaining pap smear? We may not have to pay for the thin-prep containers, but we do have to pay for the speculum, spatulas, brush, gloves, lubricant, gown, etc.

In addition, many women choose to see their PCP for the general physical exam and go to their gynecologist for the well-woman part of it. Should the gynecologist use the Preventive Medicine code for their portion of the exam....even though they don't go beyond the genitourinary system? The gynecologist should be able to code the G0101 and the Q0091 (and possibly an OV code if there is a problem-oriented issue discussed), leaving the Preventive Medicine code to the PCP. Now, what happens if the health plan will never pay the Q0091 and G0101? The gynecologist will not get paid!

I typically suggest that the Q0091 and G0101 code be coded to every health plan and not to worry which ones pay and which ones don't. It's better to code it and get paid for one or both than to not code and not get paid on either. For example, for one major healthplan, I recommend that our physicians perform and code a Preventive Medicine code first. During that visit, the physician should perform the basic preventive medicine exam and order the blood work and any other testing that is necessary for age and gender. Have the patient return to the office on another day and go over the results of the testing that has already been done, address any problem issues, and then do a well-woman exam...code the OV(with modifier -25) and the G0101 and Q0091 codes for that second visit. I understand that it is inconvenient for the patient and we try to make things convenient; but this is what the health plans require. I have actually had a particular health plan state that this is the way we should code, regardless of it being inconvenient to the patient. It's too bad, but physicians have to start looking at their bottom line!

I definitely advise people to look into the S0610 and S0612 for the gynecology visit, especially with BCBS. They will find the reimbursement rates are very good. Other health plans will reimburse the S-codes; however, Medicare will not. We are currently testing variations of coding combinations by payer to determine which is the most appropriate combination to bill by payer. This does take a lot of time on your staffs part, but it could be very cost effective if you are able to actually receive reimbursement for the services you are providing. When using the S0610/S0612, do not use the G0101 code, because they are pretty much the same code. However, I would code Q0091 in addition to the S-code if a screening pap smear was obtained.

These codes are controversial in the "coding" community; however, I firmly believe that there should be increased reimbursement for the well woman preventive exam. It truly troubles me that the Preventive Medicine codes are reimbursed the same for male and female patients. We have already established that it requires more time, more risk and requires supplies to perform the breast, pelvic and pap. The fact that some health plans want to bundle that into the Preventive Medicine exam is ridiculous! One of my goals is to inform more physicians about this and, eventually, the more physicians who take a stand, the more power we have to change the reimbursement by the health plans!

There are many physicians, billers and coders, who just accept whatever they can get as far as reimbursement. There is not enough time in a day to do appeals and really learn the various coding policies. One of the worst mistakes a physician can do is to under staff the billing department and/or not have billing people who have the means (resources) to stay abreast of all the inconsistencies in billing. The other problem that I see in our industry is that, coders especially, see only in "black and white". There is no "outside the box" for them. This is a detriment because, as we can see, the health plans do not know "black and white". Each health plan develops their own reimbursement policies that go against what coders learn. There are Medicare guidelines, CPT guidelines, BCBS guidelines, UHC guidelines...I think you get the picture! When I talk with my physicians and billing/coding staff, I will clarify that I am referring to one guideline versus another.

Now, until all physicians, coders and billers can get on the same page and insist that the health plans reimburse for the services that the physicians perform, we are going nowhere and the health plans are holding the cards! I applaud physicians and their staff for seeking information and building their understanding of this part of the industry.

Thank you for allowing me to present by opinion on this subject. Charlene Burgett,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPM Administrator, North Scottsdale Family Medicine POMAA National Advisory Board charlene_burgett@yahoo.com Invite me on LinkedIn: http://www.linkedin.com/in/charleneburgett Follow me on Twitter: http://twitter.com/CharleneBurgett

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