a Preventive Service with a Sick Visit
Documentation is the key to avoiding billing issues.
There are two types of office encounters: preventive and problem-oriented. Billing either type of visit alone is relatively straightforward, but when billing both visit types during the same encounter, documentation and billing issues can occur. We’ll focus on the Centers for Medicare 86 Medicaid Services (CMS) and CPT' rules that govern this unique billing situation.
Distinguish Preventive
Services Preventive medicine evaluation and management (E/M) visits, or annual
exams, are comprehensive exams for the sole purpose of preventive care (i.e.,
to promote wellness and disease prevention).
These services are represented by CPT ® 99381-99397. The codes are agebased,
and distinguish between new and established patients:
99382
early childhood (age 1 through 4 years)99383 late childhood (age 5 through 11 years)
99385 18-39 years
99386 40-64 years
99387 65 years and older
99391 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; infant (age younger than 1 year)
99392 early childhood (age 1 through 4 years)
99393 late childhood (age 5 through 11 years)
99394 adolescent (age 12 through 17 years)
99395 18-39 years
99396 40-64 years
99397 65 years and older
Do not confuse the term “comprehensive” used in the context of defining
a preventive service, with the definition of “comprehensive” as used in the 1995
or 1997 Documentation Guidelinesfir Evaluation andManagementServices. CPT' stresses, “The ‘comprehensive’ nature of
Preventive Medicine Services codes 99381-99397 reflects an age and ç gender
appropriate history/exam and is not synonymous with the ‘comprehensive’
examination required in Evaluation and Management codes 99201-99215.” The
extent of examination and anticipatory guidance associated with a preventive
service is based upon the provider’s judgment.
Medical Necessity ShouldDetermine Services and Coding
During a preventive exam, patients often say, “Oh, by the way.
. .,” which will prompt an additional, problem-oriented service. Several
variables influence how you report a combination preventivel problem-oriented
encounter. Billing largely depends on the payer, and sometimes on contractual
agreements, as well as provider documentation.
The key is to document what you medically need to do and bill
for what you document. In fact, this statement is my personal motto: Document
what you do and bill for what you document. CPT° 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 El M service, then the
appropriate Office/Outpatient code 99201-99215 should also be reported.”
There will likely be ‘work’ done for the problem-oriented
service that would have been performed during the course of a routine preventive
service. In other words, there will be an overlap of work. If any portion of
the history or exam was performed to satisfy the preventive service, that same
portion of work should not be used to calculate the additional level of E/ M
service. When selecting the additional El M level of service, only the work
that was performed “above and beyond ” what would have been performed during
the preventive service should be used to calculate the additional E/ M
level. Documentation needs to support
billing both services. The provider may
elect to create two separate notes to support the two separate services. This
may be the besr practice, but it also creates more work for a provider. If the
provider creates one document for both services, he or she must clearly
delineate the problem-oriented history, exam, and decision making from those of
the preventive service. For example:
- The key elements supporting the additional E/ M service must be apparent to an outside reader.
- A separate history of present illness (HPI) paragraph describing the chronic/acute condition supports additional work needed in the history (there shouldn’t be an I-IPI in a preventive service).
- The provider should clearly list in the assessment the acute / chronic conditions that are being managed at the time of the encounter. If there is a portion of the exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., “A thorough MS and neuro exam of the left hip performed as it relates to the I-IPI”).
Consider Your Payer when Billing
When billing a commercial payer, a preventive service and
additional problem-oriented El M service are billed on the same claim form and
at the full fee schedule. Some clinics may elect to reduce the fee for the
additional El M service when performed at an annual exam as a customer service
benefit. When billing Medicare, the
additional El M service must be “carved out” from the preventive service. That
is, any part of the history, physical exam, or plan portion of the annual exam
performed to address a chronic or new issue can be separated from the
non-covered preventive exam. This carved out portion of the service may be submitted
to Medicare for coverage. In this case, the overlap of work can be used to
calculate the additional level of service. Only those elements in the history,
exam, and plan that directly address the chronic illness or new problem may be
used to determine the appropriate level of E/ M. Whether you are billing to a commercial payer
or to Medicare, you must append modifier 25 Significant, separately identifiable
evaluation and management service by the same physician on the same day of theprocedure
or other service to the additional E/M code. Modifier 25
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