July 7, 2023 | By Victoria Moll, CPC, COC, CPMA, CRC, CPFC, CPRC, AAPC Approved Instructor, Fellow CEO, Contempo Coding
It’s a frequent grievance heard in the healthcare sphere – patients walk in for their “no-cost” annual exam only to walk out with a bill for a separate office visit due to an existing condition or new concern. While CPT guidelines state an office visit and preventative exam can be billed on the same day, there are a few points to consider.
First, was it medically necessary to provide the problem visit during the preventative? Let’s think back to our modifier 25 regulations in regards to it being significant and separately identifiable. If a baby goes in for a scheduled well-child check and incidentally has some diaper rash, a common concern among infants, is that significant enough to justify an office visit? If this is something the parent would have normally treated at home with some cream and would not have brought them into the office, it’s probably not a separately billable service.
What about a patient that happens to have chronic conditions and requests a refill of a prescription? Would the refill alone justify prescription drug management to bill a 99214? If this patient would have normally sent a portal message or called in for their refill and not gone into the office, there isn’t medical necessity. However, if this patient was due for a follow-up of their chronic conditions and we combined that visit with their preventative to avoid them having to make two trips to the doctor’s office, there may be justification to bill both services with the modifier 25.
The provider documentation needs to clearly distinguish between the preventative and sick visit. Each service should be individually supported with corresponding diagnoses and plan. Only the medical decision-making or time that was unrelated to the preventative examination can be utilized to calculate the separate visit. If using time, the documentation should clearly distinguish the time for the problem visit versus the preventative.
Additionally, it’s worth mentioning that the use of modifier 25 has come under the microscope recently, leading to more stringent reviews by payers. Certain payers may reduce payments for multiple visits on the same day.
It’s a delicate balance to make sure the patient doesn’t hold back from addressing any issues for fear of getting a bill during their “free” physical. While there is no cure-all, there are some measures that can be taken to improve outcomes.
When scheduling the preventative visit, the patient should be informed about the potential additional cost if an office visit is billed alongside the preventative visit. This approach not only helps in maintaining trust with patients but also minimizes disputes over unexpected charges. Practices can also post signage to remind patients as well.
Some providers prefer to reschedule the preventative visit for another time if the patient comes in with multiple complaints. This should be done in agreement with the patient and not strictly to separate dates of service for payment. Ethical considerations should always supersede financial ones.
Billing a preventative visit and an office visit on the same day requires careful consideration of several factors. It hinges on the medical necessity of the office visit, the separate and significant nature of the E&M service, thorough and specific documentation, and transparent communication with patients. The process is undoubtedly complex, and there is potential for missteps, but with careful attention to the coding rules and payer policies, it is possible to find the correct balance of when to bill both services.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
Looking to start up a medical practice or grow your existing practice? Contact our parent company, DoctorsManagement.
