Preventive and Sick Visits Same Day. Objectives

Transcription

1 Preventive and Sick Visits Same Day Brenda Chidester-Palmer CPC, CPC-I, CEMC, CCS-P AAPC National Conference June 8, 2010 Nashville, Tennessee Objectives Preventive visit definition Services included in preventive visits Differences between Sick Visit Preventive visit Guidelines on billing both services at same time CPT CMS Major carriers Documentation examples Patient factor billing and collecting 1

2 Preventive Visit Definition, cont. To fully understand documentation and billing for preventive services, we need to read the E/M Section Guidelines and the Preventive Medicine Service guidelines. Preventive Visit Definition, cont. A comprehensive preventive evaluation of an individual id that t includes an age and gender appropriate history and examination, along with counseling, anticipatory guidance and risk factor reduction. 2

3 Preventive Visit Definition, cont. CPT tells us in the guidelines: The extent and focus of the service will largely depend on the age of the patient. Preventive Visit Definition, cont. The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and a comprehensive or interval past, family and social history as well as a comprehensive assessment/history of pertinent risk factors. E/M Guidelines, page CPT 3

4 Prevent Visit Definition, cont. The comprehensive examination performed as part of the preventive medicine E/M service is multi-system, but its extent is based on age and risk factors identified. Preventive Visit Services What is actually performed and documented in a preventive visit it will differ depending di on: the patients age gender personal history family history 4

5 Preventive Visit Services, cont, All preventive visits included a review of systems and history. The answers to these questions will drive the examination and counseling/risk factor reduction portion of the visit. Preventive Visit Services, cont The exam portion of this service is not defined d CPT tells us it should be Age and gender appropriate 5

6 Preventive Visit Services, cont Medical decision making is also a component of the preventive visit it itself. The decision to order labs or other screenings services, to performing vision or hearing screens, or to administer immunizations are a part of the preventive service. The services can be billed separately Preventive Visit Services, cont. Example 1: A physician may order/perform an EKG for a 36 year old male established patient who smokes and has a family history of heart disease

7 Preventive Visit Services, cont. Example 2: A pediatrician i i sees a 5 year old for annual check-up and determines the child is due for routine immunizations DTaP-IPV MMRV Preventive Visit Services, cont Example 3: A 41 year old women presents for WWE. Physician performs exam and pap smear, orders screening mammography for this new patient

8 Preventive Visit Services, cont Example 4: A 55 year old male patient presents for routine physical after his father is diagnosed with prostate cancer. Physician performs preventive visit and orders PSA and Fecal Occult Stool tests. Preventive Visit Services, cont Remember that each preventive visit can be different, even if performed on patients t of the same age and gender. Family and personal history will play a role in what is performed and documented. Additional services may be provided or ordered based on this information. 8

9 Differences Between Preventive Medicine evaluation and management codes are used to report routine annual exams or physicals. The extent and focus of the service largely depends on the age, history and gender of the patient. E&M codes or sick visits are used to report services provided to patients who have a current illness, problem or chief complaint. These services are selected based on medical necessity and the extent or level of the service provided. Office or Sick Visit Let us briefly review what a sick visit is: Evaluation and management services that require the 3 key components: History Examination Medical Decision Making 9

10 Office or Sick Visits, cont. These elements sound a lot like the services we provide in a preventive visit it but they are different. We have to understand the differences to be able to identify which services or elements of the visit count as preventive vs. sick when we are providing and billing them on the same day. Differences Between, cont. Preventive visit Code selection based on Age of patient New or Established Diagnosis Usually V codes V20.22 V70.0 V72.31 Sick visit Code selection based on 3 Key Components History Exam Medical Decision Making New or Established Diagnosis Abd pain Strep Throat 10

11 Differences Between, cont. To really simplify this if we don t have a chief compliant we also don t have: HPI MDM related to CC Differences Between, cont. Preventive visit: Mrs. Palmer presents today for her WWE. Mammogram and pap smear are due. Sick visit: Mrs. Palmer is here complaining of sinus pressure, nasal congestion and cough x 4 days. She has used Claritin with no relieve. No fevers, no productive cough. 11

12 Differences Between, cont. Preventive visit Mr. Palmer presents today for annual physical. Sick visit Mr. Palmer is here today for HTN f/u, controlled on medication. States is feeling fine. Guidelines for Both CPT In the Preventive Services Guidelines CPT states: 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 oriented E/M service, then the appropriate Office/Outpatient code should also be reported. 12

13 Guidelines for Both CPT It also states we should append the 25 modifier to the office/outpatient ti t code to indicate a significant, separately identifiable service was performed the same day as this service. Guidelines for Both CPT If the problem or abnormality is insignificant i ifi and does not require the additional work that results in the performance of the 3 key components for an additional service, then it should NOT be reported separately. 13

14 Guidelines for Both CPT Now, all we have to figure out is What is a significant problem? Guidelines for Billing Both Services When a provider asks me how do I bill when I provide both a routine physical and a sick visit? My response is a question back to them. 14

15 Guidelines for Billing Both Services Did you also treat a significant problem? This is the KEY factor in billing an additional office service with a preventive medicine service. Guidelines for Both CPT Significant What does your provider think? Insignificant What does your provider think? 15

16 Guidelines for Both CPT The AMA gives us additional guidance on the subject of significant ifi vs. insignificant i ifi problems in the CPT Assistant, May This was the year the codes had the risk factor reduction/counseling/anticipatory guidance added to the description. CPT Assistant Examples - Both Gynecology, Family Practice and Internal Medicine A 33-year-old established female patient presents to the physician's office for her yearly gynecological examination. During the examination, the physician identifies a palpable, solitary lump in the right breast. The physician considers this finding significant enough to require additional work and the performance of the key components of a problem- oriented E/M service. Therefore, CPT code would be reported for the preventive medicine visit, and an additional code ( ) would be reported for the problem-oriented E/M service related to the breast lump. 16

17 CPT Assistant Examples - Both The appropriate problem-oriented level of E/M service should be selected based on the key components associated with providing the problem-oriented E/M service. For established patients office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. Modifier '-25' would then be appended to the office visit level of service reported, to indicate that a significant, separately identifiable E/M service was provided. CPT Assistant Examples - Both The breast lump would be reported with an ICD-9-CM CM diagnosis i code and should be associated with the problem-oriented E/M visit code reported. 17

18 CPT Assistant Examples - Both Family Practice and Internal Medicine A 55-year-old established male patient presents to the physician's office for periodic preventive medicine reevaluation and management. The patient has established diagnoses of hypertension, on beta blocker therapy, Type II diabetes controlled with sulfonylurea, and chronic stable angina controlled with sublingual nitroglycerin as needed. CPT Assistant Examples - Both A comprehensive history and examination are performed as part of the preventive medicine service. The physician counsels the patient regarding diet, exercise, and injury prevention. Risk factors are identified and interventions discussed. Medically appropriate laboratory tests and diagnostic procedures are ordered. Anticipatory guidance counseling/risk factor reduction interventions are covered to the extent that they have not been in previous preventive medicine examinations 18

19 CPT Assistant Examples - Both Furthermore, a specific history is taken and further examination is performed regarding the established diagnoses as listed above. The physician performs a problem-oriented expanded problem focused history and examination including medication compliance, diet, and stress issues. Expanded problem focused examination is given that includes vital signs, chest and heart examination, check for edema. Medical decision making of low to moderate complexity including counseling about medication and alternatives, a plan for appropriate laboratory work, review CPT Assistant Examples - Both Code would be used for the preventive medicine services visit. In addition, the appropriate p problem- oriented level of E/M service would be selected based on the key components associated with providing the problem-oriented E/M service. For established patient office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. Modifier -25 would then be appended to the office visit level of service to indicate that a significant, separately identifiable E/M service was provided. 19

20 CPT Assistant Examples - Both Pediatrics and Family Practice A woman brings her 3-year-old son, an established patient, to the physician's office for health supervision and evaluation. A comprehensive system review and comprehensive or interval past, family, and social history, as well as a comprehensive assessment/history of pertinent risk factors is performed. A comprehensive, multi-system examination is performed based on the patient's age and the risk factors identified. Speech and blood pressure are checked, while growth, development and behavior are also assessed. Immunizations are reviewed. Anticipatory i t guidance is given to the mother regarding prevention of injuries in this age group, good parenting practices, nutrition, discipline, and dental care. Risk factors are identified and interventions discussed. Medically appropriate lab tests are ordered. CPT Assistant Examples - Both During the preventive medicine encounter, the physician notes inflammation of the boy's right middle ear. Upon further questioning, the mother recalls a two-day history of the child pulling at his right ear. He has been irritable, running a low-grade fever, coughing, and has had difficulty sleeping at night. The physician then performed the key components of a problem-oriented E/M service. 20

21 CPT Assistant Examples - Both The problem-oriented E/M service included an expanded problem focused history including labored breathing, characteristics of pain in the respiratory system. The expanded problem focused examination included ears, nose, throat, chest, and hydration status. The medical decision making was of low complexity and there were discussions regarding possible need for tonsillectomy and adenoidectomy. Appropriate laboratory tests were ordered. Antibiotics were prescribed and a follow-up visit was scheduled. The physician diagnosed acute right otitis media, acute tonsillitis, and acute adenoiditis CPT Assistant Examples - Both Code would be used for the preventive medicine visit. In addition, the appropriate p problem-oriented level of E/M service should be selected based on the key components associated with providing the problemoriented E/M service. For established patient office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. Modifier -25 would then be appended to the office visit level of service to indicate that a significant, separately identifiable E/M service was provided. 21

22 Guidelines for Both CPT These examples from CPT Assistant can be used dto help educate providers and coders what to look for in documentation to submit both codes. There are numerous other scenarios that could happen at any encounter for a preventive visit. Does not meet criteria for separate visit WCE notice diaper rash writes prescription WWE on wet mount notices yeast infection writes prescription Routine physical on male refills HTN prescription with no other documentation. 22

23 Meets criteria for both visits WCE physicians notices unexplained rash on child, questions mother on changes in diet, soap, detergent etc, ask if any one else has rash, orders additional test not usually order and will have child follow-up to recheck rash WWE physician notes a breast lump orders diagnostic mammogram and possible ultrasound and schedules follow-up with patient to discuss results. Meets criteria for both Routine physical: patients states, I fell yesterday and knee continues to hurt. Physician obtains HPI, orders x-ray and prescription medication. Routine physical on male with chronic HTN: Physician notes not under control (high at this visit), questions patient if compliant with meds and diet, determines medication needs to be changed and wants patient to return for blood pressure check in a few days. 23

24 Guidelines for Both - CMS CMS also has guidance published on billing preventive services with a medically necessary E/M visit. Guidelines for Both - CMS Traditional Medicare does cover a Pelvic and Breast Exam (G0101) (following their published guidelines). does not cover annual physical exams with the exception of the Welcome to Medicare Exam. 24

25 CMS Guidelines Pelvic and Breast Screening with E/M Revenue Code and HCPCS Codes for Billing (Rev. 827, Issued: ; Effective Date: ; Implementation Date: ) 03 06) A. Billing to the Carrier Code G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination) is used. Effective for services on or after January 1, 1999, a covered evaluation and management (E/M) visit and code G0101 may be reported by the same physician for the same date of service if the E/M visit is for a separately identifiable service. In this case, the modifier -25 must be reported with the E/M service and the medical records must clearly document the E/M service reported. Both procedure codes should be shown as separate line items on the claim. These services can also be performed separately on separate office visits. CMS Guidelines IPPE with E/M Initial Preventive Physical Examination (Rev. 1615, Issued: , Effective: , Implementation: ) G. Reporting a Medically Necessary E/M Service at the Same IPPE Visit 25

26 CMS Guidelines IPPE with E/M When the physician or qualified NPP provides a medically necessary E/M service in addition to the IPPE, CPT codes may be used depending on the clinical appropriateness of the circumstances. CPT Modifier 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE code reported. CMS Guidelines IPPE with E/M NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary E/M service. 26

27 CMS Guidelines IPPE with E/M 80.2 Carrier Billing Requirements: (Rev. 1615, Issued: , 17 08, Effective: , 09, Implementation: ) Contractors shall allow payment for a medically necessary Evaluation and Management (E/M) service at the same visit as the IPPE when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use CPT codes to report an E/M with CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the IPPE code reported. CMS Guidelines Non-Covered Preventive Exam with E/M Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a non-covered preventive medicine service (CPT codes ), consider the covered visit it to be provided d in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes ) is a non-covered service. 27

28 CMS Guidelines Non-Covered Preventive Exam with E/M The physician may charge the beneficiary, as a charge for the non-covered remainder of the service, the amount by which the physician s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician s actual charge for the visit. CMS Guidelines Non-Covered Preventive Exam with E/M The physician is not required to give the beneficiary i written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury. 28

29 CMS Guidelines Non-Covered Preventive Exam with E/M The guidance for what we can bill can be simplified: The normal charge for the: routine physical is $ E/M is $60.00 We may collect: $90.00 ($ $60.00) (+20% co-insurance on the $60.00 if no secondary) CMS Guidelines Non-Covered Preventive Exam with E/M You can also go to your Medicare Carrier site to look for further guidance on these policies. 29

30 Guidelines for Both Major Carriers Regardless of what CPT publishes, or the Guidelines and Regulations set forth by CMS, other carriers can have their own policies regarding this issue. We will discuss what I call the Big 4: Aetna BCBS Cigna UHC Guidelines for Both Major Carriers AETNA Effective 2/12/06 Will pay for a problem-oriented oriented E&M visit with a modifier 25 when billed with a preventive medicine visit. Effective 8/15/09 Will apply concurrency rules (100/50) for these services. The preventive medicine service will be considered the primary procedure, payable at 100% The problem oriented E&M visit will be paid at 50% 30

31 Guidelines for Both Major Carriers BCBS BCBS of Texas has no published policy regarding payment of both of these types of E&M services. Many BCBS plans do not have benefits for routine or screening services. Guidelines for Both Major Carriers BCBS The AAFP inquired if BCBS would start paying for these services when Aetna changed their policy. The following indicated they would: BCBS of Illinois Kansas City Massachusetts 31

32 Guidelines for Both Major Carriers Cigna Modifier 25 may be used to indicate a problem-based E/M office visit (CPT ) that is significant and separately identifiable from a preventive office visit it (CPT ) on the same date of service. If modifier 25 is appended correctly, both services are separately reimbursable. Modifier 25 must be appended to the disallowed E/M office visit. View Clear Claim Connection to learn which of the two E/M services is disallowed. Documentation is not required to override the edit for problem-based and preventive office visits on the same date of service. Guidelines for Both Major Carriers Cigna The procedure that would disallow would be the office visit it ( ) 99215) The edit tells you to append the 25 modifier to the office visit codes per CPT guidelines. 32

33 Guidelines for Both Major Carriers UHC Policy # 2010R0013A Effective 3/11/09 Preventive Medicine services [Current Procedural Terminology ( CPT ) codes , , Healthcare Common Procedure Coding System (HCPCS) code G0402] include annual physical and well child examinations, usually separate from disease-related diagnoses. Guidelines for Both Major Carriers UHC Occasionally, an abnormality is encountered or a pre-existingexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, United Healthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes only or when that code is appended with modifier

34 Guidelines for Both Major Carriers UHC If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed Guidelines for Both Major Carriers UHC When a Preventive Medicine service and an E/M service from the following code series CPT codes 99211, , , , HCPCS codes G0245-G0246, M0064 are provided during the same visit, only the Preventive Medicine service will be reimbursed 34

35 Documentation Examples Lets review a few examples of notes and see if the documentation ti exists to correctly identify both services were performed: The Patient Factor Billing and Collecting Now that we know: the CPT guidelines which payers allow both what we need to document How do we answer the patients questions. 35

36 The Patient Factor Billing and Collecting Payers may waive co-pays for routine services. Most patients t are aware of this. If we provide both a preventive and sick visit, the patient will owe a co-pay on this portion and may become upset when we try to collect. Some patients will feel they did not have a significant other service. The Patient Factor Billing and Collecting Some actually wanted a sick visit but communication with the scheduler caused the appointment to be scheduled another way. 36

37 The Patient Factor Billing and Collecting Plans other than the Big 4 may not cover both services on same day, or may have different payment policies. The patient may own an entire visit balance. We need to educate our patients on what is included in a routine or annual physical, WWE, WCE, etc., prior to the service. Summary To code and document correctly we need to: Understand d the differences between the preventive visit and the sick visit Educate our providers on these difference Help them to document the services performed appropriately Know the payers guidelines Explain to the patient the services rendered 37

38 Questions? Thank you Resources mmunization_chart.html?tracking=p_related Article# (formerly (Texas Medicare) 38

39 Resources, cont. The following require logins and/or passwords: (Aetna)