If you have primary care coding questions and stress over the time it takes to find reliable answers, today’s post is for you. Among the many questions we receive from coders such as yourself, it should come as no surprise that evaluation and management concerns are the prevalent themes.
That’s why we’ve chosen to break down some tricky E/M claim issues. Read on for expert guidance to arrest potential coding errors before they siphon off your hard-earned pay.
We have been using CPT® codes 99396 or 99397 for preventive medicine visits/annual wellness visits for patients on Blue Cross Medicare Advantage plans, but we have recently been getting denials and patients are being billed for the services. Are these codes covered, or should we be using G0402 or G0438/G0439?
Answer: Payment for 99396 (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; 40-64 years) or 99397 (… 65 years and older) may depend on the Blue Cross Medicare Advantage plan in question.
Anthem Blue Cross, for example, recognizes the services and state that there “are no out-of-pocket expenses for the member … when the routine physical is completed by an in-network provider in an HMO and/or PPO plan.”
Traditional Medicare, however, does not cover 99396 and 99397, and other Blue Cross Medicare Advantage plans may follow traditional Medicare in this regard.
These services are not the same as G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment), which is commonly known as the Welcome to Medicare visit.
You should also know that these services are distinct from G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) and G0439 (… subsequent visit).
The initial preventive physical examination (IPPE) and annual wellness visit (AWV) are described as preventive, but they vary in their content. For instance, they do involve a physical exam, but clinical responsibilities for the IPPE and AWV involve more counselling and education than might occur in 99396/99397. Codes 99396/99397, on the other hand, tend to involve a more thorough physical exam.
In fact, you can actually bill for an IPPE or an AWV in addition to 99396/99397, providing you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99396/99397 if it is performed on the same day.
Our provider saw a husband and wife together and counseled them on travel medicine and immunization services prior to a trip abroad that the two were planning to make. The provider spent 25 minutes out of a 30-minute appointment on the counseling and wants to bill a 99214 for each patient, stating both patients had made individual appointments and that he would have given the same information to both of them had the patients been seen individually.
Is this accurate, or should the time be split as each patient was not counseled individually for the 25 minutes?
Answer: In terms of time, your provider met the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient. … Typically, 25 minutes are spent face-to-face with the patient and/or family) in this encounter.
However, as neither patient presented with a problem, 99214 would not be appropriate. Counseling regarding travel medicine and immunization would be regarded as preventive in nature, so a code from 99401-99429 Counseling Risk Factor Reduction and Behavior Change Intervention codes would be more accurate. CPT® guidelines for those codes make this clear: “Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”
But this does not mean you should reach for 99402 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes) and bill it twice in this situation.
Even though the code meets the time requirement of your provider’s situation, the descriptor clearly states that this is a service “provided to an individual.” Your provider counseled two people together, which means 99411 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes) would be most appropriate in this circumstance, as it not only meets the time requirement, but it also addresses the group nature of the counseling.
Because the code describes counseling provided to “individuals in a group setting,” you may report it once for each person in the group (i.e., the husband and wife in this scenario).
An established 66-year-old patient presented to our provider. She did not state a specific complaint. The doctor ordered a basic metabolic panel, venipuncture, a dipstick urinalysis, and a complete blood count with differential.
The patient’s results came back showing nothing abnormal: the urinalysis dipstick with leukocytes was negative; nitrite negative; urobilinogen: 0.2; protein: trace; pH: 6.0; blood: negative; specific gravity: 1.030; ketone: negative; bilirubin: negative; glucose: negative; the appearance was clear and the color pale yellow. The basic metabolic panel notes that glucose is 98; BUN: 12; CA: 9.0; CRE: 1.0; NA: 140; K: 3.9; CL: 103; and TCO2: 24.
What level evaluation and management (E/M) code should I report for this encounter?
Answer: The level of E/M in this, and any, encounter depends on the history, physical exam, and level of medical decision making (MDM) the provider documents, which is not clear from your question.
When none of these things is present in the note for an established patient, the only level of E/M that can be reported is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal …) since the descriptor does not reference history, exam, or MDM. Even then, the note should reflect that some evaluation and management of the patient occurred.
In this case, as you point out, even a chief complaint is missing from the note. A chief complaint is integral to a visit note and requires a concise statement, usually in the patient’s own words, of some symptom, condition, or diagnosis that is the reason for the visit. Without it, there is no justification to bill for an E/M, and even 99211 is probably off the table for this visit.
So, you may only be able to report the laboratory services your practice performed, and assuming your practice did the tests ordered by the physician, your bill should only reflect something like the following:
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