Coding, Classification and Reimbursement

Preventive Visit and E/M

  • 1.  Preventive Visit and E/M

    Posted 08-15-2018 16:04

    Hi,

    I have read that if a patient comes in for a preventive visit and an abnormality is encountered during the exam you can add an E/M visit with a modifier 25.

    One of my providers has asked, if the patient comes in for a regular physical ( not an annual gynecological exam) and has complaint of a vaginal issue, so she has to do a gynecological exam ( which is beyond what she would normally do in a regular physical exam), could she code a preventive visit and an E/M visit?

    Thank you,

    Brooke Mason



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    Brooke Mason
    Medical Billing and Coding Coordinator
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  • 2.  RE: Preventive Visit and E/M

    Posted 08-16-2018 07:18
    Edited by April McQuaig 08-16-2018 07:23
    ​This is true however the documentation MUST support that there was enough done to constitute the additional code being billed. Essentially there has to be documentation of the preventative exam as well as enough supporting documentation on the additional issue to support a low level visit on its own. We have doctors at our practice that look over the routine lab work, determine the patient has something like hyperlipidemia or vitamin D deficiency and try to bill an additional E/M with the physical and we do not allow that. If the patient brings up something like recurrent chest pain, the doctor spends additional time getting the background - how long its been going on, how often, what circumstances, any relieving factors, any additional testing ordered - then we will add the -25 modifier and bill a 99212 in addition to the physical. For something like your describing the vaginal exam being done with the physical alone would not support an additional E/M being billed because the vaginal exam is always bundled as part of a physical, it would still need all of the above mentioned background information documented. I would note that when this is done, the insurances will process the 99212 with a co-pay even being done with a physical/preventative visit. Nearly every time this is done we get a call from the patient asking why their "free visit" had a co-pay charged.

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    April McQuaig CCS
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  • 3.  RE: Preventive Visit and E/M

    Posted 08-16-2018 12:53

    Thank you for your response. So just to clarify, even if the patient already had her annual gynecological visit earlier in the year, but has now returned for just a regular physical ( ex: for work or school), and presents with a vaginal issue  and the provider has to take a history, do an exam, etc. for the vaginal issue, you can only code for the physical?

    Thank you,

    Brooke Mason



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    Brooke Mason
    Medical Billing and Coding Coordinator
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  • 4.  RE: Preventive Visit and E/M

    Posted 08-17-2018 07:13
    ​No, that is not what I said. You can bill for both the physical and a low level exam for the newly presented issue as long as there is clear documentation that supports an additional low level exam being done. "If the patient brings up something like recurrent chest pain, the doctor spends additional time getting the background - how long its been going on, how often, what circumstances, any relieving factors, any additional testing ordered - then we will add the -25 modifier and bill a 99212 in addition to the physical. For something like your describing the vaginal exam being done with the physical alone would not support an additional E/M being billed because the vaginal exam is always bundled as part of a physical, it would still need all of the above mentioned background information documented." To clarify, if there is only documentation of a vaginal exam, not any background information on the issue, you can not bill an additional E/M. Again, you need background information on the newly presented issue documented to support an additional E/M code being billed.

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    April McQuaig CCS
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  • 5.  RE: Preventive Visit and E/M

    Posted 21 days ago
    April is correct. I always tell my providers they must, in their minds, separate their documentation of the problem from the preventive exam documentation.
    There needs to be an HPI regarding the vaginal problem ( how long have the symptoms been present, what has been tried to treat the problem, etc), possibly a ROS. I would only count the GU, if a ROS was asked, toward the problem focused E&M. The physical exam I would again count the GU. If a med was prescribed then of course that would count as well.


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    Tracy Graham, CCS, CPhT
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