October 01, 2013
Area(s) of Interest: Emergency Services Hospitals and Health Facilities Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Often, a patient who arrives for a “preventive” service (i.e., a well patient exam) will also mention a problem or other health issue that he or she is experiencing. Whether you separately report a problem-focused service – in addition to the preventive service – depends on the nature of the patient’s problem(s), the payer and your documentation.
If the patient has a major complaint or illness, you probably shouldn’t provide the preventive service at the same time because you would be unable to obtain a good “baseline.” In such a case, you’d do better to reschedule the preventive service for another time and focus the current visit on the present patient complaint.
If the patient complaint is relatively minor, but nevertheless requires additional workup beyond that usually associated with the preventive service, you may choose to report a problem-focused visit in addition to the preventive service.
The CPT® codebook instructs, “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 components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.”
Documentation must support both services. If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work may not be used to calculate the additional level of E/M service. A separate history of present illness (HPI) describing the patient’s complaint supports additional work in the history (there’s no HPI for a preventive service). If a portion of the exam performed is not routine for a preventive service, clearly identify that portion.
Remember: When selecting the additional E/M level of service, only the work “above and beyond” what would have been performed during the preventive service may be counted toward the problem-focused visit.
Lastly, when reporting the preventive visit and a problem-focused visit on the same day, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service to the problem-focused visit code.
For example, a 30-year-old established patient injures her ankle on the morning of a scheduled routine examination. Provider documentation supports a problem-focused history related to the ankle injury, a problem-focused examination of the ankle, and medical straightforward decision-making, as well as a comprehensive preventive medicine service.
The appropriate coding for a commercial payer is 99212-25 Office or other outpatient visit for the evaluation and management of an established patient… with a diagnosis from ICD-9-CM category 845.xx Sprains and strains of ankle. You would also report 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years with V70.0 Routine general medical examination.
Note that commercial payers’ policies vary. Some will not pay for two evaluation and management services on one date of service, or may reduce payment for one of the services. Check with the payer to verify both the coding policy, and the patient’s benefits.
Alert Patients to Costs
When billing Medicare (which specifies its own codes for many preventive services), any additional E/M service must be “carved out” from the preventive service. This portion of the service may be submitted to Medicare for coverage. The Medicare beneficiary may be billed for the difference between the standard fee for the preventive service and the amount that Medicare will cover. Patients may be confused to see two bills for one office visit. Educating patients prior to billing can help to avoid potential confusion and complaints.