Article of Interest
April
21, 2014
ARTICLE DETAIL:
Author : Betsy Nicoletti
Article Date: 4/16/2014
Title: Coding for Both a Preventive
Service and Problem-oriented
Source: Physician Practice [
physicianpractice.com ]
We
have been asked this question many of times. I came across this article and
found it to be interest. However, it does answer the question correctly. The
key issue is VERIFICATION. Your office should check with the carriers for
further clarification. LCD or NMP the article displays the correct method.
What doctor hasn't heard this before: "While I'm
here, I'd like to discuss a few problems."
The patient
presents for an annual preventive medicine service and arrives in the exam room
with a long list of concerns, questions, and complaints; some pre-existing and
some new. The clinician wants to discuss screening tests, healthy behaviors,
and risk factor reductions, but the patient has another agenda. So what do you
do?
There are three possible solutions, none of
them perfect for this situation: provide two services for the price of one; ask
the patient to schedule another appointment; or bill for both. Each of these is
coded differently and each has financial and patient satisfaction implications.
The CPT book states:
"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 also be reported."
The May 2002 CPT
Assistant newsletter provides additional detail and clinical vignettes on this
topic. Its examples include treating both new and established problems, and
recommend reporting both the preventive medicine service (99381-99397) and a
problem-oriented visit. The problem-oriented visit is reported with the
diagnosis for the condition that is treated, and the preventive medicine
service is reported with a diagnosis code for an examination. Append modifier -25
to the problem-oriented visit.
A preventive
medicine service is an age and gender appropriate history and exam and includes
anticipatory guidance, a discussion about risk factor reduction, and provision
or referral for immunizations and screening tests. The history recorded, the
exam performed, and the content of advice will vary by the age and gender of
the patient.
A problem-oriented
visit is one that addresses an acute or chronic condition and documents
history, exam, and medical decision making related to the condition.
1. Two for the price of one
Some clinicians
report only a preventive medicine service, even when addressing multiple acute
or chronic issues. Why? Medical practices report that many payers won't
reimburse for the second service and that patients, expecting a free preventive
service, are angry when there is a copay or the charge goes to the deductible.
It is true: Collecting from insurance companies is difficult, most state
Medicaid programs will only pay for one E&M on a calendar date, and
patients are angry when they get a bill for a service they thought was free,
yet has a cost. But, is this reason enough to provide two services for the
price of one? "I'll have the hamburger and the fish and chips, but only
charge me for the hamburger."
2. Set up another appointment
For a patient in a
medical crisis, the clinician will reschedule the preventive service. But, this
is also an option for a patient with multiple problems to address. Tell the
patient there isn't time to do his annual exam and address his list of seven
problems. Perform one that day and re-schedule the others. If the clinician
does the physical, ask the patient to identify his most pressing concern and
treat it.
3. Perform and bill for both
If both services
are done, follow the CPT rules and report both the preventive service and the
problem-oriented visit. The patient will be charged a copay for the
problem-oriented visit, or may be charged full fee for that visit, depending on
her insurance coverage. Be prepared for complaints, and be sure the
documentation is complete.
Some coders
recommend two notes, one for the preventive service and one for the
problem-oriented visit. This isn't very practical in EHR. But, if reporting
both, take care in documenting the part of the visit that supports the
non-preventive portion of the visit. In the history of the present illness,
describe the patient's symptoms or her chronic conditions. Don't conserve
words. "HTN-stable; DM-okay; Lipids-will check," will hardly justify
the addition of a problem-oriented visit.
Also, if the entire
HPI is copied from a previous visit, don't report an additional visit. In the
HPI, document pertinent positive and negative systems related to the presenting
problem. In the assessment and plan, list the conditions treated and changes to
the treatment. You should be more likely to report a problem-oriented visit
when there is a new acute condition, a worsening chronic condition, a
diagnostic test was ordered, or a treatment was changed. Refilling
prescriptions for existing problems is not sufficient work to report a
problem-oriented visit, in addition to the preventive service.
Clinicians in the
same practice group may have different philosophies and practices regarding
this issue. It is useful to discuss these with the billing and coding staff and
to develop a written policy. Consistency in implementing the policy helps both
clinicians and staff answer patient questions.
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