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Re: [CRN-L] Preventative and E&M services

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  • Bloom Viola
    If I am understanding your answer correctly then: the chronic conditions are subtarcted from the other part of the exam which is the preventative portion, and
    Message 1 of 17 , Aug 1, 2004
      If I am understanding your answer correctly then: the chronic conditions are subtarcted from the other part of the exam which is the preventative portion, and that would reduce the amount that you would get for the annual visit. I am just a coder and I am trying to get the big picture here. I am just starting to learn the actual billing part. So from a coders side would you still code the chronic conditions whether they are stable or not, and also the preventative code if it is an annual visit with the modifier 25? I really appreciate all of the advice and help for everyone on this group. Thank you.

      Jo Ann Steigerwald <jsteiger@...> wrote:I was referring specifically to Medicare in my post; for Medicare patients,
      you must subtract the "covered" visit from the noncovered service, and your
      total charge for the office services cannot exceed your "regular"
      preventive medicine visit charge.

      Jo Ann S

      At 10:13 AM 7/31/2004, you wrote:
      >I usually code both the preventative code and the office visit code, some
      >insurances pay both, others I have to appeal and I have the providers
      >clearly document that add'l problems were discussed during the exam. Is
      >that right?
      >
      >Kristina Creech
      >M.R.S. Inc
      >Mobile 919-291-8449
      >CONFIDENTIALITY NOTICE: This email message, including any attachments,
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      >
      > > [Original Message]
      > > From: Jo Ann Steigerwald
      > > To:
      > > Date: 07/31/2004 12:57:24 AM
      > > Subject: Re: [CRN-L] Preventative and E&M services
      > >
      > > Look at it this way: go through the history, PFSH, ROS, exam and
      >decision
      > > making and "count" any portions that would have been done anyway (without
      > > an annual exam) based on the patient's presenting health conditions; in
      > > other words, if the patient is coming in for rechecks at two or three
      >month
      > > intervals (not unusual for patients with that list of medical problems),
      > > what portions of the service are done "anyway".
      > >
      > > The "extra" ones are the preventive medicine exam portion, the portions
      >of
      > > the exam that are not "medically necessary" at this time based on the
      > > patient's prsenting conditions. So what you are looking at is if the
      > > patient came "only" for the known conditions for medication refills for
      > > example, what portions of the exam would need to be done.
      > >
      > > For example, in the first patient shown in your note, the "eye" exam is
      > > related to listed conditions, but ENT was probably not related to any of
      > > those. The neck, heart and lungs are clearly done for known conditions,
      >as
      > > is the abdomen, probably the extremities and skin. genital exam would be
      > > "necessary" in this patient because of possible prostate disease
      >(nocturia)
      > > (which is NOT leaving a lot for preventive medicine).
      > >
      > > Also, do keep in mind that when you charge "two" visits, you are actually
      > > subtracting the charges for the "medically necessary" visit from your
      > > standard charge for the preventive medicne service, and billing the
      >patient
      > > the difference between the two (plus appropriate copay and deductible;
      >you
      > > aren't actually charging out two complete visits.
      > >
      > > Jo Ann S
      > >
      > >
      > > At 10:43 PM 7/30/2004, you wrote:
      > > >Could someone explain to me how to code an annual exam for patients
      > > >that have chronic conditions that may or may not be stable during an
      > > >annual exam.
      > > >Example 1: 65 year old patient is being seen for his annual exam
      > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
      > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
      > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
      > > >25 for annual exam and 99213 for the E&M level.
      > > >Example 2: 74 year old patient is being seen for his annual exam
      > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
      > > >for the annual exam and the 99397 for the visit.
      > > >No one seems to be able to explain to me how to code a preventative
      > > >and what seems to be an E&M level at the same time. I thought that
      > > >chronic conditions should be coded during an annual exam even if they
      > > >are stable, because they affect the patients care and there are
      > > >prescriptions to refill for these conditions. Most of the patients
      > > >that are seen in the facility that I am at have quite a few chronic
      > > >conditions. If this was a case of a younger patient coming in for
      > > >there annual exam that is allowed by their insurance once a year I
      > > >could see coding just the annual exam.
      > > >Thank you to everyone in advance.
      > > >
      > > >
      > > >
      > > >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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      >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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    • Jo Ann Steigerwald
      Exactly - for Medicare patients because Medicare doesn t cover preventive medicine visits...so this allows you to bill Medicare for the medically necessary
      Message 2 of 17 , Aug 1, 2004
        Exactly - for Medicare patients because Medicare doesn't cover preventive
        medicine visits...so this allows you to bill Medicare for the "medically
        necessary" portion of the visit that you'd need to do anyway, and only bill
        the patient for the true amount that Medicare will not pay - the annual
        screening exam portion of the visit.

        The issue isn't whether the conditions are "stable" or not - its the
        "medically necessary" portion of the visit that you have to do to manage
        the aptient's condition, and establishing that they are "stable" (and thus
        any current medications etc are adequate at this time) is part of the
        medically necessary portion of the visit.

        Medicare won't allow you to charge for both visits because you'd be
        getting paid twice for the same visit....but they will pick up part of the
        charges. Needless to say, this is a different situation from non-Medicare
        patients who are likely to have preventive medicine coverage.

        Jo Ann S



        At 12:46 PM 8/1/2004, you wrote:
        >If I am understanding your answer correctly then: the chronic conditions
        >are subtarcted from the other part of the exam which is the preventative
        >portion, and that would reduce the amount that you would get for the
        >annual visit. I am just a coder and I am trying to get the big picture
        >here. I am just starting to learn the actual billing part. So from a
        >coders side would you still code the chronic conditions whether they are
        >stable or not, and also the preventative code if it is an annual visit
        >with the modifier 25? I really appreciate all of the advice and help for
        >everyone on this group. Thank you.
        >
        >Jo Ann Steigerwald <jsteiger@...> wrote:I was referring
        >specifically to Medicare in my post; for Medicare patients,
        >you must subtract the "covered" visit from the noncovered service, and your
        >total charge for the office services cannot exceed your "regular"
        >preventive medicine visit charge.
        >
        >Jo Ann S
        >
        >At 10:13 AM 7/31/2004, you wrote:
        > >I usually code both the preventative code and the office visit code, some
        > >insurances pay both, others I have to appeal and I have the providers
        > >clearly document that add'l problems were discussed during the exam. Is
        > >that right?
        > >
        > >Kristina Creech
        > >M.R.S. Inc
        > >Mobile 919-291-8449
        > >CONFIDENTIALITY NOTICE: This email message, including any attachments,
        > >is for the sole use of the intended recipient(s) to which it is addressed
        > >and
        > >may contain confidential, privileged or proprietary information. Any
        > >unauthorized review, use, disclosure or distribution is prohibited. If you
        > >are not the intended recipient, you are not authorized to read, print,
        > >retain, copy or disseminate this message, attachments or any part of
        > >them. If you have received this message in error, please notify the sender
        > >immediately and destroy the original message, attachments and all copies
        > >thereof.
        > >
        > >
        > > > [Original Message]
        > > > From: Jo Ann Steigerwald
        > > > To:
        > > > Date: 07/31/2004 12:57:24 AM
        > > > Subject: Re: [CRN-L] Preventative and E&M services
        > > >
        > > > Look at it this way: go through the history, PFSH, ROS, exam and
        > >decision
        > > > making and "count" any portions that would have been done anyway (without
        > > > an annual exam) based on the patient's presenting health conditions; in
        > > > other words, if the patient is coming in for rechecks at two or three
        > >month
        > > > intervals (not unusual for patients with that list of medical problems),
        > > > what portions of the service are done "anyway".
        > > >
        > > > The "extra" ones are the preventive medicine exam portion, the portions
        > >of
        > > > the exam that are not "medically necessary" at this time based on the
        > > > patient's prsenting conditions. So what you are looking at is if the
        > > > patient came "only" for the known conditions for medication refills for
        > > > example, what portions of the exam would need to be done.
        > > >
        > > > For example, in the first patient shown in your note, the "eye" exam is
        > > > related to listed conditions, but ENT was probably not related to any of
        > > > those. The neck, heart and lungs are clearly done for known conditions,
        > >as
        > > > is the abdomen, probably the extremities and skin. genital exam would be
        > > > "necessary" in this patient because of possible prostate disease
        > >(nocturia)
        > > > (which is NOT leaving a lot for preventive medicine).
        > > >
        > > > Also, do keep in mind that when you charge "two" visits, you are actually
        > > > subtracting the charges for the "medically necessary" visit from your
        > > > standard charge for the preventive medicne service, and billing the
        > >patient
        > > > the difference between the two (plus appropriate copay and deductible;
        > >you
        > > > aren't actually charging out two complete visits.
        > > >
        > > > Jo Ann S
        > > >
        > > >
        > > > At 10:43 PM 7/30/2004, you wrote:
        > > > >Could someone explain to me how to code an annual exam for patients
        > > > >that have chronic conditions that may or may not be stable during an
        > > > >annual exam.
        > > > >Example 1: 65 year old patient is being seen for his annual exam
        > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
        > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
        > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
        > > > >25 for annual exam and 99213 for the E&M level.
        > > > >Example 2: 74 year old patient is being seen for his annual exam
        > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
        > > > >for the annual exam and the 99397 for the visit.
        > > > >No one seems to be able to explain to me how to code a preventative
        > > > >and what seems to be an E&M level at the same time. I thought that
        > > > >chronic conditions should be coded during an annual exam even if they
        > > > >are stable, because they affect the patients care and there are
        > > > >prescriptions to refill for these conditions. Most of the patients
        > > > >that are seen in the facility that I am at have quite a few chronic
        > > > >conditions. If this was a case of a younger patient coming in for
        > > > >there annual exam that is allowed by their insurance once a year I
        > > > >could see coding just the annual exam.
        > > > >Thank you to everyone in advance.
        > > > >
        > > > >
        > > > >
        > > > >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
        > > > >CLICK ME LINKS:
        > > > >CodeCorrect 10% off for CRN Members when you sign up at
        > > > >http://crn.codecorrect.com 15% off for Gold Members - contact
        > > > >Laureen@... for details.
        > > > >
        > > > >Optimize physician service reimbursement compliantly:
        > > > >http://www.cfs-billing.com
        > > > >
        > > > >CEU TeleCourseTM Training & Videos
        > > > >http://www.crn-institute.com
        > > > >
        > > > >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
        > > > >
        > > > >CRN Homepage:
        > > > >http://www.codingandreimbursement.net
        > > > >Become a CRN Gold Member!
        > > > >http://www.codingandreimbursement.net/GoGold.htm
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        > > > [Non-text portions of this message have been removed]
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        > > > ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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        > >Laureen@... for details.
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        > > > Optimize physician service reimbursement compliantly:
        > >http://www.cfs-billing.com
        > > >
        > > > CEU TeleCourseTM Training & Videos
        > > > http://www.crn-institute.com
        > > >
        > > > ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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        > > > CRN Homepage:
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        > > > Become a CRN Gold Member!
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      • Bloom Viola
        So when coding for annual exam and an E&M at the same time you would list all chronic codes with any current dx codes for the visit. The billing department
        Message 3 of 17 , Aug 1, 2004
          So when coding for annual exam and an E&M at the same time you would list all chronic codes with any current dx codes for the visit. The billing department would then take care of only billing for the chronic conditions and any other conditions that are found at the time of the encounter not the annual visit when billing Medicare. Now what is done when the pt is does not have Medicare? All chronic conditions are coded along with any other conditions found during the encounter. You would also code for the annual exam correct with the modifier 25 and the level of E&M. From the coding stand point I want to know that I am coding per guidelines, not just for the biller. They will subtract what needs to be when billing for Medicare. My biggest problem besides understanding the big picture is knowing that my coding is correct for this type of situation. There are five other coders in the facility whom just code, and know one seems to be consistant with what they are coding when it
          comes to preventative and E&M coding during the same encounter. Thank you very much.

          Jo Ann Steigerwald <jsteiger@...> wrote:Exactly - for Medicare patients because Medicare doesn't cover preventive
          medicine visits...so this allows you to bill Medicare for the "medically
          necessary" portion of the visit that you'd need to do anyway, and only bill
          the patient for the true amount that Medicare will not pay - the annual
          screening exam portion of the visit.

          The issue isn't whether the conditions are "stable" or not - its the
          "medically necessary" portion of the visit that you have to do to manage
          the aptient's condition, and establishing that they are "stable" (and thus
          any current medications etc are adequate at this time) is part of the
          medically necessary portion of the visit.

          Medicare won't allow you to charge for both visits because you'd be
          getting paid twice for the same visit....but they will pick up part of the
          charges. Needless to say, this is a different situation from non-Medicare
          patients who are likely to have preventive medicine coverage.

          Jo Ann S



          At 12:46 PM 8/1/2004, you wrote:
          >If I am understanding your answer correctly then: the chronic conditions
          >are subtarcted from the other part of the exam which is the preventative
          >portion, and that would reduce the amount that you would get for the
          >annual visit. I am just a coder and I am trying to get the big picture
          >here. I am just starting to learn the actual billing part. So from a
          >coders side would you still code the chronic conditions whether they are
          >stable or not, and also the preventative code if it is an annual visit
          >with the modifier 25? I really appreciate all of the advice and help for
          >everyone on this group. Thank you.
          >
          >Jo Ann Steigerwald wrote:I was referring
          >specifically to Medicare in my post; for Medicare patients,
          >you must subtract the "covered" visit from the noncovered service, and your
          >total charge for the office services cannot exceed your "regular"
          >preventive medicine visit charge.
          >
          >Jo Ann S
          >
          >At 10:13 AM 7/31/2004, you wrote:
          > >I usually code both the preventative code and the office visit code, some
          > >insurances pay both, others I have to appeal and I have the providers
          > >clearly document that add'l problems were discussed during the exam. Is
          > >that right?
          > >
          > >Kristina Creech
          > >M.R.S. Inc
          > >Mobile 919-291-8449
          > >CONFIDENTIALITY NOTICE: This email message, including any attachments,
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          > >
          > > > [Original Message]
          > > > From: Jo Ann Steigerwald
          > > > To:
          > > > Date: 07/31/2004 12:57:24 AM
          > > > Subject: Re: [CRN-L] Preventative and E&M services
          > > >
          > > > Look at it this way: go through the history, PFSH, ROS, exam and
          > >decision
          > > > making and "count" any portions that would have been done anyway (without
          > > > an annual exam) based on the patient's presenting health conditions; in
          > > > other words, if the patient is coming in for rechecks at two or three
          > >month
          > > > intervals (not unusual for patients with that list of medical problems),
          > > > what portions of the service are done "anyway".
          > > >
          > > > The "extra" ones are the preventive medicine exam portion, the portions
          > >of
          > > > the exam that are not "medically necessary" at this time based on the
          > > > patient's prsenting conditions. So what you are looking at is if the
          > > > patient came "only" for the known conditions for medication refills for
          > > > example, what portions of the exam would need to be done.
          > > >
          > > > For example, in the first patient shown in your note, the "eye" exam is
          > > > related to listed conditions, but ENT was probably not related to any of
          > > > those. The neck, heart and lungs are clearly done for known conditions,
          > >as
          > > > is the abdomen, probably the extremities and skin. genital exam would be
          > > > "necessary" in this patient because of possible prostate disease
          > >(nocturia)
          > > > (which is NOT leaving a lot for preventive medicine).
          > > >
          > > > Also, do keep in mind that when you charge "two" visits, you are actually
          > > > subtracting the charges for the "medically necessary" visit from your
          > > > standard charge for the preventive medicne service, and billing the
          > >patient
          > > > the difference between the two (plus appropriate copay and deductible;
          > >you
          > > > aren't actually charging out two complete visits.
          > > >
          > > > Jo Ann S
          > > >
          > > >
          > > > At 10:43 PM 7/30/2004, you wrote:
          > > > >Could someone explain to me how to code an annual exam for patients
          > > > >that have chronic conditions that may or may not be stable during an
          > > > >annual exam.
          > > > >Example 1: 65 year old patient is being seen for his annual exam
          > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
          > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
          > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
          > > > >25 for annual exam and 99213 for the E&M level.
          > > > >Example 2: 74 year old patient is being seen for his annual exam
          > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
          > > > >for the annual exam and the 99397 for the visit.
          > > > >No one seems to be able to explain to me how to code a preventative
          > > > >and what seems to be an E&M level at the same time. I thought that
          > > > >chronic conditions should be coded during an annual exam even if they
          > > > >are stable, because they affect the patients care and there are
          > > > >prescriptions to refill for these conditions. Most of the patients
          > > > >that are seen in the facility that I am at have quite a few chronic
          > > > >conditions. If this was a case of a younger patient coming in for
          > > > >there annual exam that is allowed by their insurance once a year I
          > > > >could see coding just the annual exam.
          > > > >Thank you to everyone in advance.
          > > > >
          > > > >
          > > > >
          > > > >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
          > > > >CLICK ME LINKS:
          > > > >CodeCorrect 10% off for CRN Members when you sign up at
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        • Jo Ann Steigerwald
          First of all, it sounds like you are referring to diagnosis codes, not CPT codes. The chronic condition codes should, of course, be used with the medically
          Message 4 of 17 , Aug 1, 2004
            First of all, it sounds like you are referring to diagnosis codes, not CPT
            codes. The chronic condition codes should, of course, be used with the
            "medically necessary" portion E/M code.

            If the patient does NOT have Medicare, the issue becomes how much work was
            actually done that would NOT have been done with a routine annual exam? In
            the E/M's I've reviewed for this specific issue, most of them did not have
            appreciable amounts of work over and above the work one would expect to see
            for a "routine annual exam" unless the patient presented with an acute, new
            onset condition of signicance. Because many (not all but many) patients DO
            have coverage for annual exams, "spliting the visit" is not as critical
            for those patients, and for the most part, if you attempt to charge out a
            second visit on the same date of service, it will be denied by the payer,
            or the allowed amount for the preventive medicine service is just
            artitrarily split into two payments for the two services.

            IMO, except in unusual circumstances, what you will collect is generally
            not worth the extra work for non-Medicare patients.

            What makes it worhwhile (although still a lot of work) in Medicare patients
            is that physicians for the most part will go ahead and "do" annual complete
            exams on Medicare patients anyway (coverage not=withstanding) and the
            billers/coders are left with either falsely billing the entire service to
            Medicare, or splitting the visit and billing the appropriate portion to the
            patient. This avoid, at least, billing the patient for the entire amount
            of a preventive medicine visit, something most physicians don't want to do.

            Jo Ann S

            At 02:45 PM 8/1/2004, you wrote:
            >So when coding for annual exam and an E&M at the same time you would list
            >all chronic codes with any current dx codes for the visit. The billing
            >department would then take care of only billing for the chronic conditions
            >and any other conditions that are found at the time of the encounter not
            >the annual visit when billing Medicare. Now what is done when the pt is
            >does not have Medicare? All chronic conditions are coded along with any
            >other conditions found during the encounter. You would also code for the
            >annual exam correct with the modifier 25 and the level of E&M. From the
            >coding stand point I want to know that I am coding per guidelines, not
            >just for the biller. They will subtract what needs to be when billing for
            >Medicare. My biggest problem besides understanding the big picture is
            >knowing that my coding is correct for this type of situation. There are
            >five other coders in the facility whom just code, and know one seems to be
            >consistant with what they are coding when it
            > comes to preventative and E&M coding during the same encounter. Thank
            > you very much.
            >
            >Jo Ann Steigerwald <jsteiger@...> wrote:Exactly - for Medicare
            >patients because Medicare doesn't cover preventive
            >medicine visits...so this allows you to bill Medicare for the "medically
            >necessary" portion of the visit that you'd need to do anyway, and only bill
            >the patient for the true amount that Medicare will not pay - the annual
            >screening exam portion of the visit.
            >
            >The issue isn't whether the conditions are "stable" or not - its the
            >"medically necessary" portion of the visit that you have to do to manage
            >the aptient's condition, and establishing that they are "stable" (and thus
            >any current medications etc are adequate at this time) is part of the
            >medically necessary portion of the visit.
            >
            >Medicare won't allow you to charge for both visits because you'd be
            >getting paid twice for the same visit....but they will pick up part of the
            >charges. Needless to say, this is a different situation from non-Medicare
            >patients who are likely to have preventive medicine coverage.
            >
            >Jo Ann S
            >
            >
            >
            >At 12:46 PM 8/1/2004, you wrote:
            > >If I am understanding your answer correctly then: the chronic conditions
            > >are subtarcted from the other part of the exam which is the preventative
            > >portion, and that would reduce the amount that you would get for the
            > >annual visit. I am just a coder and I am trying to get the big picture
            > >here. I am just starting to learn the actual billing part. So from a
            > >coders side would you still code the chronic conditions whether they are
            > >stable or not, and also the preventative code if it is an annual visit
            > >with the modifier 25? I really appreciate all of the advice and help for
            > >everyone on this group. Thank you.
            > >
            > >Jo Ann Steigerwald wrote:I was referring
            > >specifically to Medicare in my post; for Medicare patients,
            > >you must subtract the "covered" visit from the noncovered service, and your
            > >total charge for the office services cannot exceed your "regular"
            > >preventive medicine visit charge.
            > >
            > >Jo Ann S
            > >
            > >At 10:13 AM 7/31/2004, you wrote:
            > > >I usually code both the preventative code and the office visit code, some
            > > >insurances pay both, others I have to appeal and I have the providers
            > > >clearly document that add'l problems were discussed during the exam. Is
            > > >that right?
            > > >
            > > >Kristina Creech
            > > >M.R.S. Inc
            > > >Mobile 919-291-8449
            > > >CONFIDENTIALITY NOTICE: This email message, including any attachments,
            > > >is for the sole use of the intended recipient(s) to which it is addressed
            > > >and
            > > >may contain confidential, privileged or proprietary information. Any
            > > >unauthorized review, use, disclosure or distribution is prohibited. If you
            > > >are not the intended recipient, you are not authorized to read, print,
            > > >retain, copy or disseminate this message, attachments or any part of
            > > >them. If you have received this message in error, please notify the sender
            > > >immediately and destroy the original message, attachments and all copies
            > > >thereof.
            > > >
            > > >
            > > > > [Original Message]
            > > > > From: Jo Ann Steigerwald
            > > > > To:
            > > > > Date: 07/31/2004 12:57:24 AM
            > > > > Subject: Re: [CRN-L] Preventative and E&M services
            > > > >
            > > > > Look at it this way: go through the history, PFSH, ROS, exam and
            > > >decision
            > > > > making and "count" any portions that would have been done anyway
            > (without
            > > > > an annual exam) based on the patient's presenting health conditions; in
            > > > > other words, if the patient is coming in for rechecks at two or three
            > > >month
            > > > > intervals (not unusual for patients with that list of medical
            > problems),
            > > > > what portions of the service are done "anyway".
            > > > >
            > > > > The "extra" ones are the preventive medicine exam portion, the portions
            > > >of
            > > > > the exam that are not "medically necessary" at this time based on the
            > > > > patient's prsenting conditions. So what you are looking at is if the
            > > > > patient came "only" for the known conditions for medication refills for
            > > > > example, what portions of the exam would need to be done.
            > > > >
            > > > > For example, in the first patient shown in your note, the "eye" exam is
            > > > > related to listed conditions, but ENT was probably not related to
            > any of
            > > > > those. The neck, heart and lungs are clearly done for known conditions,
            > > >as
            > > > > is the abdomen, probably the extremities and skin. genital exam
            > would be
            > > > > "necessary" in this patient because of possible prostate disease
            > > >(nocturia)
            > > > > (which is NOT leaving a lot for preventive medicine).
            > > > >
            > > > > Also, do keep in mind that when you charge "two" visits, you are
            > actually
            > > > > subtracting the charges for the "medically necessary" visit from your
            > > > > standard charge for the preventive medicne service, and billing the
            > > >patient
            > > > > the difference between the two (plus appropriate copay and deductible;
            > > >you
            > > > > aren't actually charging out two complete visits.
            > > > >
            > > > > Jo Ann S
            > > > >
            > > > >
            > > > > At 10:43 PM 7/30/2004, you wrote:
            > > > > >Could someone explain to me how to code an annual exam for patients
            > > > > >that have chronic conditions that may or may not be stable during an
            > > > > >annual exam.
            > > > > >Example 1: 65 year old patient is being seen for his annual exam
            > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
            > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
            > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
            > > > > >25 for annual exam and 99213 for the E&M level.
            > > > > >Example 2: 74 year old patient is being seen for his annual exam
            > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
            > > > > >for the annual exam and the 99397 for the visit.
            > > > > >No one seems to be able to explain to me how to code a preventative
            > > > > >and what seems to be an E&M level at the same time. I thought that
            > > > > >chronic conditions should be coded during an annual exam even if they
            > > > > >are stable, because they affect the patients care and there are
            > > > > >prescriptions to refill for these conditions. Most of the patients
            > > > > >that are seen in the facility that I am at have quite a few chronic
            > > > > >conditions. If this was a case of a younger patient coming in for
            > > > > >there annual exam that is allowed by their insurance once a year I
            > > > > >could see coding just the annual exam.
            > > > > >Thank you to everyone in advance.
            > > > > >
            > > > > >
            > > > > >
            > > > > >~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
            > > > > >CLICK ME LINKS:
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            > > > > >Optimize physician service reimbursement compliantly:
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            > > > > >
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          • Jo Ann Steigerwald
            Could someone post the link to change E-mail address on CRN? I can t find it on the website.... [Non-text portions of this message have been removed]
            Message 5 of 17 , Aug 1, 2004
              Could someone post the link to change E-mail address on CRN? I can't find
              it on the website....

              [Non-text portions of this message have been removed]
            • Bloom Viola
              Jo Ann, I am sorry if I am sounding redundent. I am new to the world of coding. I have been working at this facility to get the needed experience. I am
              Message 6 of 17 , Aug 1, 2004
                Jo Ann, I am sorry if I am sounding redundent. I am new to the world of coding. I have been working at this facility to get the needed experience. I am like an old dog with a bone when it comes to something I don't quite understand and I see the coders at the facility all coding differently and know one is giving me good answers as to why they are doing what they are when coding this situation. Some of the coders code all ICD-9-CM codes for the chronic conditions along with the CPT code for level of E&M and the appropriate CPT code for annual exam with the modifier 25. Then there are those that just leave off the chronic condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam and the CPT code for appropriate annual exam. I just believe that there is only one correct way to give all of the appropriate ICD-9-CM codes and CPT codes no matter who the insurance is through if there is any. Am I wrong in believeing that you code all ICD-9-CM codes for all lisited
                chronic conditions and if there are any new acute conditions at the visit with the V code for the exam, and the appropriate CPT annual exam code with modifier 25 and then the CPT level for E&M for that visit. And then what correct order of sequencing is there for this visit? Sorry I am long winded.


                Jo Ann Steigerwald <jsteiger@...> wrote:
                First of all, it sounds like you are referring to diagnosis codes, not CPT
                codes. The chronic condition codes should, of course, be used with the
                "medically necessary" portion E/M code.

                If the patient does NOT have Medicare, the issue becomes how much work was
                actually done that would NOT have been done with a routine annual exam? In
                the E/M's I've reviewed for this specific issue, most of them did not have
                appreciable amounts of work over and above the work one would expect to see
                for a "routine annual exam" unless the patient presented with an acute, new
                onset condition of signicance. Because many (not all but many) patients DO
                have coverage for annual exams, "spliting the visit" is not as critical
                for those patients, and for the most part, if you attempt to charge out a
                second visit on the same date of service, it will be denied by the payer,
                or the allowed amount for the preventive medicine service is just
                artitrarily split into two payments for the two services.

                IMO, except in unusual circumstances, what you will collect is generally
                not worth the extra work for non-Medicare patients.

                What makes it worhwhile (although still a lot of work) in Medicare patients
                is that physicians for the most part will go ahead and "do" annual complete
                exams on Medicare patients anyway (coverage not=withstanding) and the
                billers/coders are left with either falsely billing the entire service to
                Medicare, or splitting the visit and billing the appropriate portion to the
                patient. This avoid, at least, billing the patient for the entire amount
                of a preventive medicine visit, something most physicians don't want to do.

                Jo Ann S

                At 02:45 PM 8/1/2004, you wrote:
                >So when coding for annual exam and an E&M at the same time you would list
                >all chronic codes with any current dx codes for the visit. The billing
                >department would then take care of only billing for the chronic conditions
                >and any other conditions that are found at the time of the encounter not
                >the annual visit when billing Medicare. Now what is done when the pt is
                >does not have Medicare? All chronic conditions are coded along with any
                >other conditions found during the encounter. You would also code for the
                >annual exam correct with the modifier 25 and the level of E&M. From the
                >coding stand point I want to know that I am coding per guidelines, not
                >just for the biller. They will subtract what needs to be when billing for
                >Medicare. My biggest problem besides understanding the big picture is
                >knowing that my coding is correct for this type of situation. There are
                >five other coders in the facility whom just code, and know one seems to be
                >consistant with what they are coding when it
                > comes to preventative and E&M coding during the same encounter. Thank
                > you very much.
                >
                >Jo Ann Steigerwald wrote:Exactly - for Medicare
                >patients because Medicare doesn't cover preventive
                >medicine visits...so this allows you to bill Medicare for the "medically
                >necessary" portion of the visit that you'd need to do anyway, and only bill
                >the patient for the true amount that Medicare will not pay - the annual
                >screening exam portion of the visit.
                >
                >The issue isn't whether the conditions are "stable" or not - its the
                >"medically necessary" portion of the visit that you have to do to manage
                >the aptient's condition, and establishing that they are "stable" (and thus
                >any current medications etc are adequate at this time) is part of the
                >medically necessary portion of the visit.
                >
                >Medicare won't allow you to charge for both visits because you'd be
                >getting paid twice for the same visit....but they will pick up part of the
                >charges. Needless to say, this is a different situation from non-Medicare
                >patients who are likely to have preventive medicine coverage.
                >
                >Jo Ann S
                >
                >
                >
                >At 12:46 PM 8/1/2004, you wrote:
                > >If I am understanding your answer correctly then: the chronic conditions
                > >are subtarcted from the other part of the exam which is the preventative
                > >portion, and that would reduce the amount that you would get for the
                > >annual visit. I am just a coder and I am trying to get the big picture
                > >here. I am just starting to learn the actual billing part. So from a
                > >coders side would you still code the chronic conditions whether they are
                > >stable or not, and also the preventative code if it is an annual visit
                > >with the modifier 25? I really appreciate all of the advice and help for
                > >everyone on this group. Thank you.
                > >
                > >Jo Ann Steigerwald wrote:I was referring
                > >specifically to Medicare in my post; for Medicare patients,
                > >you must subtract the "covered" visit from the noncovered service, and your
                > >total charge for the office services cannot exceed your "regular"
                > >preventive medicine visit charge.
                > >
                > >Jo Ann S
                > >
                > >At 10:13 AM 7/31/2004, you wrote:
                > > >I usually code both the preventative code and the office visit code, some
                > > >insurances pay both, others I have to appeal and I have the providers
                > > >clearly document that add'l problems were discussed during the exam. Is
                > > >that right?
                > > >
                > > >Kristina Creech
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                > > >
                > > > > [Original Message]
                > > > > From: Jo Ann Steigerwald
                > > > > To:
                > > > > Date: 07/31/2004 12:57:24 AM
                > > > > Subject: Re: [CRN-L] Preventative and E&M services
                > > > >
                > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                > > >decision
                > > > > making and "count" any portions that would have been done anyway
                > (without
                > > > > an annual exam) based on the patient's presenting health conditions; in
                > > > > other words, if the patient is coming in for rechecks at two or three
                > > >month
                > > > > intervals (not unusual for patients with that list of medical
                > problems),
                > > > > what portions of the service are done "anyway".
                > > > >
                > > > > The "extra" ones are the preventive medicine exam portion, the portions
                > > >of
                > > > > the exam that are not "medically necessary" at this time based on the
                > > > > patient's prsenting conditions. So what you are looking at is if the
                > > > > patient came "only" for the known conditions for medication refills for
                > > > > example, what portions of the exam would need to be done.
                > > > >
                > > > > For example, in the first patient shown in your note, the "eye" exam is
                > > > > related to listed conditions, but ENT was probably not related to
                > any of
                > > > > those. The neck, heart and lungs are clearly done for known conditions,
                > > >as
                > > > > is the abdomen, probably the extremities and skin. genital exam
                > would be
                > > > > "necessary" in this patient because of possible prostate disease
                > > >(nocturia)
                > > > > (which is NOT leaving a lot for preventive medicine).
                > > > >
                > > > > Also, do keep in mind that when you charge "two" visits, you are
                > actually
                > > > > subtracting the charges for the "medically necessary" visit from your
                > > > > standard charge for the preventive medicne service, and billing the
                > > >patient
                > > > > the difference between the two (plus appropriate copay and deductible;
                > > >you
                > > > > aren't actually charging out two complete visits.
                > > > >
                > > > > Jo Ann S
                > > > >
                > > > >
                > > > > At 10:43 PM 7/30/2004, you wrote:
                > > > > >Could someone explain to me how to code an annual exam for patients
                > > > > >that have chronic conditions that may or may not be stable during an
                > > > > >annual exam.
                > > > > >Example 1: 65 year old patient is being seen for his annual exam
                > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
                > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
                > > > > >25 for annual exam and 99213 for the E&M level.
                > > > > >Example 2: 74 year old patient is being seen for his annual exam
                > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
                > > > > >for the annual exam and the 99397 for the visit.
                > > > > >No one seems to be able to explain to me how to code a preventative
                > > > > >and what seems to be an E&M level at the same time. I thought that
                > > > > >chronic conditions should be coded during an annual exam even if they
                > > > > >are stable, because they affect the patients care and there are
                > > > > >prescriptions to refill for these conditions. Most of the patients
                > > > > >that are seen in the facility that I am at have quite a few chronic
                > > > > >conditions. If this was a case of a younger patient coming in for
                > > > > >there annual exam that is allowed by their insurance once a year I
                > > > > >could see coding just the annual exam.
                > > > > >Thank you to everyone in advance.
                > > > > >
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              • Jo Ann Steigerwald
                If you are using a preventive medicine code, the V could should go out first (as the reason for the visit) on all payers...Some payers will not accept a
                Message 7 of 17 , Aug 1, 2004
                  If you are using a preventive medicine code, the V could should go out
                  first (as the "reason" for the visit) on all payers...Some payers will not
                  accept a preventive medicine code if it has additional diagnosis codes
                  attached. Correctly done, you should sequence the "first" diagnosis as the
                  one that reflects the "reason" the patient scheduled the visit....in this
                  case a V code, and include any conditions that were addressed during this
                  visit as secondary codes. (Address may be treated directly, or those
                  conditions documented as impacting the outcome in some way, such as a child
                  presenting with an URI who is asthmatic: URI first, asthma second, unless
                  the chld presented for problems with the asthma because there is an
                  underlying URI).

                  In the end, you must consider the charges being submitted for payment and
                  the payer requirements; if the patient has preventive medicine coverage,
                  and presented for an "annual exam" and the payer will not accept additional
                  codes with the preventive medicne codes, use only the V-code; use additonal
                  codes if the payer will accept them.

                  Most likely the variations you are seeing are at least in part due to
                  varying requirements by payers, and there is no way to get around complying
                  with payer requirements if you are going to get the claims paid.

                  The error that I see most commonly is leaving off secondary diagnoses
                  altogether when a payer will accept them (and in cases collects the
                  information), and includng chronic and past history codes when there is
                  nothing in the documentation to show that the condition was addressed.

                  Another error is charging an "separate" visit when what was done was
                  actually a prescription refill.....The doctor has reviewed current meds as
                  part of past history, and while there is some "decision making" involved in
                  writing an RX, that alone is probably not enough to justify an entirely
                  separate visit in addition to the "complete H&P" for an annual exam, either
                  to the patient or the payer.

                  Jo Ann S



                  At 03:18 PM 8/1/2004, you wrote:
                  >Jo Ann, I am sorry if I am sounding redundent. I am new to the world of
                  >coding. I have been working at this facility to get the needed
                  >experience. I am like an old dog with a bone when it comes to something I
                  >don't quite understand and I see the coders at the facility all coding
                  >differently and know one is giving me good answers as to why they are
                  >doing what they are when coding this situation. Some of the coders code
                  >all ICD-9-CM codes for the chronic conditions along with the CPT code for
                  >level of E&M and the appropriate CPT code for annual exam with the
                  >modifier 25. Then there are those that just leave off the chronic
                  >condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam
                  >and the CPT code for appropriate annual exam. I just believe that there
                  >is only one correct way to give all of the appropriate ICD-9-CM codes and
                  >CPT codes no matter who the insurance is through if there is any. Am I
                  >wrong in believeing that you code all ICD-9-CM codes for all lisited
                  > chronic conditions and if there are any new acute conditions at the
                  > visit with the V code for the exam, and the appropriate CPT annual exam
                  > code with modifier 25 and then the CPT level for E&M for that visit. And
                  > then what correct order of sequencing is there for this visit? Sorry I
                  > am long winded.
                  >
                  >
                  >Jo Ann Steigerwald <jsteiger@...> wrote:
                  >First of all, it sounds like you are referring to diagnosis codes, not CPT
                  >codes. The chronic condition codes should, of course, be used with the
                  >"medically necessary" portion E/M code.
                  >
                  >If the patient does NOT have Medicare, the issue becomes how much work was
                  >actually done that would NOT have been done with a routine annual exam? In
                  >the E/M's I've reviewed for this specific issue, most of them did not have
                  >appreciable amounts of work over and above the work one would expect to see
                  >for a "routine annual exam" unless the patient presented with an acute, new
                  >onset condition of signicance. Because many (not all but many) patients DO
                  >have coverage for annual exams, "spliting the visit" is not as critical
                  >for those patients, and for the most part, if you attempt to charge out a
                  >second visit on the same date of service, it will be denied by the payer,
                  >or the allowed amount for the preventive medicine service is just
                  >artitrarily split into two payments for the two services.
                  >
                  >IMO, except in unusual circumstances, what you will collect is generally
                  >not worth the extra work for non-Medicare patients.
                  >
                  >What makes it worhwhile (although still a lot of work) in Medicare patients
                  >is that physicians for the most part will go ahead and "do" annual complete
                  >exams on Medicare patients anyway (coverage not=withstanding) and the
                  >billers/coders are left with either falsely billing the entire service to
                  >Medicare, or splitting the visit and billing the appropriate portion to the
                  >patient. This avoid, at least, billing the patient for the entire amount
                  >of a preventive medicine visit, something most physicians don't want to do.
                  >
                  >Jo Ann S
                  >
                  >At 02:45 PM 8/1/2004, you wrote:
                  > >So when coding for annual exam and an E&M at the same time you would list
                  > >all chronic codes with any current dx codes for the visit. The billing
                  > >department would then take care of only billing for the chronic conditions
                  > >and any other conditions that are found at the time of the encounter not
                  > >the annual visit when billing Medicare. Now what is done when the pt is
                  > >does not have Medicare? All chronic conditions are coded along with any
                  > >other conditions found during the encounter. You would also code for the
                  > >annual exam correct with the modifier 25 and the level of E&M. From the
                  > >coding stand point I want to know that I am coding per guidelines, not
                  > >just for the biller. They will subtract what needs to be when billing for
                  > >Medicare. My biggest problem besides understanding the big picture is
                  > >knowing that my coding is correct for this type of situation. There are
                  > >five other coders in the facility whom just code, and know one seems to be
                  > >consistant with what they are coding when it
                  > > comes to preventative and E&M coding during the same encounter. Thank
                  > > you very much.
                  > >
                  > >Jo Ann Steigerwald wrote:Exactly - for Medicare
                  > >patients because Medicare doesn't cover preventive
                  > >medicine visits...so this allows you to bill Medicare for the "medically
                  > >necessary" portion of the visit that you'd need to do anyway, and only bill
                  > >the patient for the true amount that Medicare will not pay - the annual
                  > >screening exam portion of the visit.
                  > >
                  > >The issue isn't whether the conditions are "stable" or not - its the
                  > >"medically necessary" portion of the visit that you have to do to manage
                  > >the aptient's condition, and establishing that they are "stable" (and thus
                  > >any current medications etc are adequate at this time) is part of the
                  > >medically necessary portion of the visit.
                  > >
                  > >Medicare won't allow you to charge for both visits because you'd be
                  > >getting paid twice for the same visit....but they will pick up part of the
                  > >charges. Needless to say, this is a different situation from non-Medicare
                  > >patients who are likely to have preventive medicine coverage.
                  > >
                  > >Jo Ann S
                  > >
                  > >
                  > >
                  > >At 12:46 PM 8/1/2004, you wrote:
                  > > >If I am understanding your answer correctly then: the chronic conditions
                  > > >are subtarcted from the other part of the exam which is the preventative
                  > > >portion, and that would reduce the amount that you would get for the
                  > > >annual visit. I am just a coder and I am trying to get the big picture
                  > > >here. I am just starting to learn the actual billing part. So from a
                  > > >coders side would you still code the chronic conditions whether they are
                  > > >stable or not, and also the preventative code if it is an annual visit
                  > > >with the modifier 25? I really appreciate all of the advice and help for
                  > > >everyone on this group. Thank you.
                  > > >
                  > > >Jo Ann Steigerwald wrote:I was referring
                  > > >specifically to Medicare in my post; for Medicare patients,
                  > > >you must subtract the "covered" visit from the noncovered service, and
                  > your
                  > > >total charge for the office services cannot exceed your "regular"
                  > > >preventive medicine visit charge.
                  > > >
                  > > >Jo Ann S
                  > > >
                  > > >At 10:13 AM 7/31/2004, you wrote:
                  > > > >I usually code both the preventative code and the office visit code,
                  > some
                  > > > >insurances pay both, others I have to appeal and I have the providers
                  > > > >clearly document that add'l problems were discussed during the exam. Is
                  > > > >that right?
                  > > > >
                  > > > >Kristina Creech
                  > > > >M.R.S. Inc
                  > > > >Mobile 919-291-8449
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                  > > > >
                  > > > > > [Original Message]
                  > > > > > From: Jo Ann Steigerwald
                  > > > > > To:
                  > > > > > Date: 07/31/2004 12:57:24 AM
                  > > > > > Subject: Re: [CRN-L] Preventative and E&M services
                  > > > > >
                  > > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                  > > > >decision
                  > > > > > making and "count" any portions that would have been done anyway
                  > > (without
                  > > > > > an annual exam) based on the patient's presenting health
                  > conditions; in
                  > > > > > other words, if the patient is coming in for rechecks at two or three
                  > > > >month
                  > > > > > intervals (not unusual for patients with that list of medical
                  > > problems),
                  > > > > > what portions of the service are done "anyway".
                  > > > > >
                  > > > > > The "extra" ones are the preventive medicine exam portion, the
                  > portions
                  > > > >of
                  > > > > > the exam that are not "medically necessary" at this time based on the
                  > > > > > patient's prsenting conditions. So what you are looking at is if the
                  > > > > > patient came "only" for the known conditions for medication
                  > refills for
                  > > > > > example, what portions of the exam would need to be done.
                  > > > > >
                  > > > > > For example, in the first patient shown in your note, the "eye"
                  > exam is
                  > > > > > related to listed conditions, but ENT was probably not related to
                  > > any of
                  > > > > > those. The neck, heart and lungs are clearly done for known
                  > conditions,
                  > > > >as
                  > > > > > is the abdomen, probably the extremities and skin. genital exam
                  > > would be
                  > > > > > "necessary" in this patient because of possible prostate disease
                  > > > >(nocturia)
                  > > > > > (which is NOT leaving a lot for preventive medicine).
                  > > > > >
                  > > > > > Also, do keep in mind that when you charge "two" visits, you are
                  > > actually
                  > > > > > subtracting the charges for the "medically necessary" visit from your
                  > > > > > standard charge for the preventive medicne service, and billing the
                  > > > >patient
                  > > > > > the difference between the two (plus appropriate copay and
                  > deductible;
                  > > > >you
                  > > > > > aren't actually charging out two complete visits.
                  > > > > >
                  > > > > > Jo Ann S
                  > > > > >
                  > > > > >
                  > > > > > At 10:43 PM 7/30/2004, you wrote:
                  > > > > > >Could someone explain to me how to code an annual exam for patients
                  > > > > > >that have chronic conditions that may or may not be stable during an
                  > > > > > >annual exam.
                  > > > > > >Example 1: 65 year old patient is being seen for his annual exam
                  > > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
                  > > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                  > > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg.
                  > 99397-
                  > > > > > >25 for annual exam and 99213 for the E&M level.
                  > > > > > >Example 2: 74 year old patient is being seen for his annual exam
                  > > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
                  > > > > > >for the annual exam and the 99397 for the visit.
                  > > > > > >No one seems to be able to explain to me how to code a preventative
                  > > > > > >and what seems to be an E&M level at the same time. I thought that
                  > > > > > >chronic conditions should be coded during an annual exam even if
                  > they
                  > > > > > >are stable, because they affect the patients care and there are
                  > > > > > >prescriptions to refill for these conditions. Most of the patients
                  > > > > > >that are seen in the facility that I am at have quite a few chronic
                  > > > > > >conditions. If this was a case of a younger patient coming in for
                  > > > > > >there annual exam that is allowed by their insurance once a year I
                  > > > > > >could see coding just the annual exam.
                  > > > > > >Thank you to everyone in advance.
                  > > > > > >
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                • Bloom Viola
                  Thank you, you have been so helpful. Now on to the documentation for the preventative and E&M visit. The several physicians at this facility Iist all of the
                  Message 8 of 17 , Aug 1, 2004
                    Thank you, you have been so helpful. Now on to the documentation for the preventative and E&M visit. The several physicians at this facility Iist all of the chronic conditions even if they don't directly talk about them. I code all of these because he has them in his dx list. I am assuming this is ok since he put them on his list of dxs. I always code certain chronic conditions such as diabetes, HTN, CAD, COPD, Hyperlimpidemia etc. As long as the doctor has them on his dx list even though he doesn't directly address them is it correct to code them like I have been doing? I am talking for E&M visits and preventative.

                    Jo Ann Steigerwald <jsteiger@...> wrote:If you are using a preventive medicine code, the V could should go out
                    first (as the "reason" for the visit) on all payers...Some payers will not
                    accept a preventive medicine code if it has additional diagnosis codes
                    attached. Correctly done, you should sequence the "first" diagnosis as the
                    one that reflects the "reason" the patient scheduled the visit....in this
                    case a V code, and include any conditions that were addressed during this
                    visit as secondary codes. (Address may be treated directly, or those
                    conditions documented as impacting the outcome in some way, such as a child
                    presenting with an URI who is asthmatic: URI first, asthma second, unless
                    the chld presented for problems with the asthma because there is an
                    underlying URI).

                    In the end, you must consider the charges being submitted for payment and
                    the payer requirements; if the patient has preventive medicine coverage,
                    and presented for an "annual exam" and the payer will not accept additional
                    codes with the preventive medicne codes, use only the V-code; use additonal
                    codes if the payer will accept them.

                    Most likely the variations you are seeing are at least in part due to
                    varying requirements by payers, and there is no way to get around complying
                    with payer requirements if you are going to get the claims paid.

                    The error that I see most commonly is leaving off secondary diagnoses
                    altogether when a payer will accept them (and in cases collects the
                    information), and includng chronic and past history codes when there is
                    nothing in the documentation to show that the condition was addressed.

                    Another error is charging an "separate" visit when what was done was
                    actually a prescription refill.....The doctor has reviewed current meds as
                    part of past history, and while there is some "decision making" involved in
                    writing an RX, that alone is probably not enough to justify an entirely
                    separate visit in addition to the "complete H&P" for an annual exam, either
                    to the patient or the payer.

                    Jo Ann S



                    At 03:18 PM 8/1/2004, you wrote:
                    >Jo Ann, I am sorry if I am sounding redundent. I am new to the world of
                    >coding. I have been working at this facility to get the needed
                    >experience. I am like an old dog with a bone when it comes to something I
                    >don't quite understand and I see the coders at the facility all coding
                    >differently and know one is giving me good answers as to why they are
                    >doing what they are when coding this situation. Some of the coders code
                    >all ICD-9-CM codes for the chronic conditions along with the CPT code for
                    >level of E&M and the appropriate CPT code for annual exam with the
                    >modifier 25. Then there are those that just leave off the chronic
                    >condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam
                    >and the CPT code for appropriate annual exam. I just believe that there
                    >is only one correct way to give all of the appropriate ICD-9-CM codes and
                    >CPT codes no matter who the insurance is through if there is any. Am I
                    >wrong in believeing that you code all ICD-9-CM codes for all lisited
                    > chronic conditions and if there are any new acute conditions at the
                    > visit with the V code for the exam, and the appropriate CPT annual exam
                    > code with modifier 25 and then the CPT level for E&M for that visit. And
                    > then what correct order of sequencing is there for this visit? Sorry I
                    > am long winded.
                    >
                    >
                    >Jo Ann Steigerwald wrote:
                    >First of all, it sounds like you are referring to diagnosis codes, not CPT
                    >codes. The chronic condition codes should, of course, be used with the
                    >"medically necessary" portion E/M code.
                    >
                    >If the patient does NOT have Medicare, the issue becomes how much work was
                    >actually done that would NOT have been done with a routine annual exam? In
                    >the E/M's I've reviewed for this specific issue, most of them did not have
                    >appreciable amounts of work over and above the work one would expect to see
                    >for a "routine annual exam" unless the patient presented with an acute, new
                    >onset condition of signicance. Because many (not all but many) patients DO
                    >have coverage for annual exams, "spliting the visit" is not as critical
                    >for those patients, and for the most part, if you attempt to charge out a
                    >second visit on the same date of service, it will be denied by the payer,
                    >or the allowed amount for the preventive medicine service is just
                    >artitrarily split into two payments for the two services.
                    >
                    >IMO, except in unusual circumstances, what you will collect is generally
                    >not worth the extra work for non-Medicare patients.
                    >
                    >What makes it worhwhile (although still a lot of work) in Medicare patients
                    >is that physicians for the most part will go ahead and "do" annual complete
                    >exams on Medicare patients anyway (coverage not=withstanding) and the
                    >billers/coders are left with either falsely billing the entire service to
                    >Medicare, or splitting the visit and billing the appropriate portion to the
                    >patient. This avoid, at least, billing the patient for the entire amount
                    >of a preventive medicine visit, something most physicians don't want to do.
                    >
                    >Jo Ann S
                    >
                    >At 02:45 PM 8/1/2004, you wrote:
                    > >So when coding for annual exam and an E&M at the same time you would list
                    > >all chronic codes with any current dx codes for the visit. The billing
                    > >department would then take care of only billing for the chronic conditions
                    > >and any other conditions that are found at the time of the encounter not
                    > >the annual visit when billing Medicare. Now what is done when the pt is
                    > >does not have Medicare? All chronic conditions are coded along with any
                    > >other conditions found during the encounter. You would also code for the
                    > >annual exam correct with the modifier 25 and the level of E&M. From the
                    > >coding stand point I want to know that I am coding per guidelines, not
                    > >just for the biller. They will subtract what needs to be when billing for
                    > >Medicare. My biggest problem besides understanding the big picture is
                    > >knowing that my coding is correct for this type of situation. There are
                    > >five other coders in the facility whom just code, and know one seems to be
                    > >consistant with what they are coding when it
                    > > comes to preventative and E&M coding during the same encounter. Thank
                    > > you very much.
                    > >
                    > >Jo Ann Steigerwald wrote:Exactly - for Medicare
                    > >patients because Medicare doesn't cover preventive
                    > >medicine visits...so this allows you to bill Medicare for the "medically
                    > >necessary" portion of the visit that you'd need to do anyway, and only bill
                    > >the patient for the true amount that Medicare will not pay - the annual
                    > >screening exam portion of the visit.
                    > >
                    > >The issue isn't whether the conditions are "stable" or not - its the
                    > >"medically necessary" portion of the visit that you have to do to manage
                    > >the aptient's condition, and establishing that they are "stable" (and thus
                    > >any current medications etc are adequate at this time) is part of the
                    > >medically necessary portion of the visit.
                    > >
                    > >Medicare won't allow you to charge for both visits because you'd be
                    > >getting paid twice for the same visit....but they will pick up part of the
                    > >charges. Needless to say, this is a different situation from non-Medicare
                    > >patients who are likely to have preventive medicine coverage.
                    > >
                    > >Jo Ann S
                    > >
                    > >
                    > >
                    > >At 12:46 PM 8/1/2004, you wrote:
                    > > >If I am understanding your answer correctly then: the chronic conditions
                    > > >are subtarcted from the other part of the exam which is the preventative
                    > > >portion, and that would reduce the amount that you would get for the
                    > > >annual visit. I am just a coder and I am trying to get the big picture
                    > > >here. I am just starting to learn the actual billing part. So from a
                    > > >coders side would you still code the chronic conditions whether they are
                    > > >stable or not, and also the preventative code if it is an annual visit
                    > > >with the modifier 25? I really appreciate all of the advice and help for
                    > > >everyone on this group. Thank you.
                    > > >
                    > > >Jo Ann Steigerwald wrote:I was referring
                    > > >specifically to Medicare in my post; for Medicare patients,
                    > > >you must subtract the "covered" visit from the noncovered service, and
                    > your
                    > > >total charge for the office services cannot exceed your "regular"
                    > > >preventive medicine visit charge.
                    > > >
                    > > >Jo Ann S
                    > > >
                    > > >At 10:13 AM 7/31/2004, you wrote:
                    > > > >I usually code both the preventative code and the office visit code,
                    > some
                    > > > >insurances pay both, others I have to appeal and I have the providers
                    > > > >clearly document that add'l problems were discussed during the exam. Is
                    > > > >that right?
                    > > > >
                    > > > >Kristina Creech
                    > > > >M.R.S. Inc
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                    > > > >
                    > > > > > [Original Message]
                    > > > > > From: Jo Ann Steigerwald
                    > > > > > To:
                    > > > > > Date: 07/31/2004 12:57:24 AM
                    > > > > > Subject: Re: [CRN-L] Preventative and E&M services
                    > > > > >
                    > > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                    > > > >decision
                    > > > > > making and "count" any portions that would have been done anyway
                    > > (without
                    > > > > > an annual exam) based on the patient's presenting health
                    > conditions; in
                    > > > > > other words, if the patient is coming in for rechecks at two or three
                    > > > >month
                    > > > > > intervals (not unusual for patients with that list of medical
                    > > problems),
                    > > > > > what portions of the service are done "anyway".
                    > > > > >
                    > > > > > The "extra" ones are the preventive medicine exam portion, the
                    > portions
                    > > > >of
                    > > > > > the exam that are not "medically necessary" at this time based on the
                    > > > > > patient's prsenting conditions. So what you are looking at is if the
                    > > > > > patient came "only" for the known conditions for medication
                    > refills for
                    > > > > > example, what portions of the exam would need to be done.
                    > > > > >
                    > > > > > For example, in the first patient shown in your note, the "eye"
                    > exam is
                    > > > > > related to listed conditions, but ENT was probably not related to
                    > > any of
                    > > > > > those. The neck, heart and lungs are clearly done for known
                    > conditions,
                    > > > >as
                    > > > > > is the abdomen, probably the extremities and skin. genital exam
                    > > would be
                    > > > > > "necessary" in this patient because of possible prostate disease
                    > > > >(nocturia)
                    > > > > > (which is NOT leaving a lot for preventive medicine).
                    > > > > >
                    > > > > > Also, do keep in mind that when you charge "two" visits, you are
                    > > actually
                    > > > > > subtracting the charges for the "medically necessary" visit from your
                    > > > > > standard charge for the preventive medicne service, and billing the
                    > > > >patient
                    > > > > > the difference between the two (plus appropriate copay and
                    > deductible;
                    > > > >you
                    > > > > > aren't actually charging out two complete visits.
                    > > > > >
                    > > > > > Jo Ann S
                    > > > > >
                    > > > > >
                    > > > > > At 10:43 PM 7/30/2004, you wrote:
                    > > > > > >Could someone explain to me how to code an annual exam for patients
                    > > > > > >that have chronic conditions that may or may not be stable during an
                    > > > > > >annual exam.
                    > > > > > >Example 1: 65 year old patient is being seen for his annual exam
                    > > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
                    > > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                    > > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg.
                    > 99397-
                    > > > > > >25 for annual exam and 99213 for the E&M level.
                    > > > > > >Example 2: 74 year old patient is being seen for his annual exam
                    > > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
                    > > > > > >for the annual exam and the 99397 for the visit.
                    > > > > > >No one seems to be able to explain to me how to code a preventative
                    > > > > > >and what seems to be an E&M level at the same time. I thought that
                    > > > > > >chronic conditions should be coded during an annual exam even if
                    > they
                    > > > > > >are stable, because they affect the patients care and there are
                    > > > > > >prescriptions to refill for these conditions. Most of the patients
                    > > > > > >that are seen in the facility that I am at have quite a few chronic
                    > > > > > >conditions. If this was a case of a younger patient coming in for
                    > > > > > >there annual exam that is allowed by their insurance once a year I
                    > > > > > >could see coding just the annual exam.
                    > > > > > >Thank you to everyone in advance.
                    > > > > > >
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                  • Jo Ann Steigerwald
                    Generally, you also see system-related ROS and past history or current history that addresses those conditions; you d also see items in the physical exam
                    Message 9 of 17 , Aug 1, 2004
                      Generally, you also see system-related ROS and past history or current
                      history that addresses those conditions; you'd also see items in the
                      physical exam related to the systems....putting all of that together, the
                      physician has addressed the concerns.




                      At 04:44 PM 8/1/2004, you wrote:
                      >Thank you, you have been so helpful. Now on to the documentation for the
                      >preventative and E&M visit. The several physicians at this facility Iist
                      >all of the chronic conditions even if they don't directly talk about
                      >them. I code all of these because he has them in his dx list. I am
                      >assuming this is ok since he put them on his list of dxs. I always code
                      >certain chronic conditions such as diabetes, HTN, CAD, COPD,
                      >Hyperlimpidemia etc. As long as the doctor has them on his dx list even
                      >though he doesn't directly address them is it correct to code them like I
                      >have been doing? I am talking for E&M visits and preventative.
                      >
                      >Jo Ann Steigerwald <jsteiger@...> wrote:If you are using a
                      >preventive medicine code, the V could should go out
                      >first (as the "reason" for the visit) on all payers...Some payers will not
                      >accept a preventive medicine code if it has additional diagnosis codes
                      >attached. Correctly done, you should sequence the "first" diagnosis as the
                      >one that reflects the "reason" the patient scheduled the visit....in this
                      >case a V code, and include any conditions that were addressed during this
                      >visit as secondary codes. (Address may be treated directly, or those
                      >conditions documented as impacting the outcome in some way, such as a child
                      >presenting with an URI who is asthmatic: URI first, asthma second, unless
                      >the chld presented for problems with the asthma because there is an
                      >underlying URI).
                      >
                      >In the end, you must consider the charges being submitted for payment and
                      >the payer requirements; if the patient has preventive medicine coverage,
                      >and presented for an "annual exam" and the payer will not accept additional
                      >codes with the preventive medicne codes, use only the V-code; use additonal
                      >codes if the payer will accept them.
                      >
                      >Most likely the variations you are seeing are at least in part due to
                      >varying requirements by payers, and there is no way to get around complying
                      >with payer requirements if you are going to get the claims paid.
                      >
                      >The error that I see most commonly is leaving off secondary diagnoses
                      >altogether when a payer will accept them (and in cases collects the
                      >information), and includng chronic and past history codes when there is
                      >nothing in the documentation to show that the condition was addressed.
                      >
                      >Another error is charging an "separate" visit when what was done was
                      >actually a prescription refill.....The doctor has reviewed current meds as
                      >part of past history, and while there is some "decision making" involved in
                      >writing an RX, that alone is probably not enough to justify an entirely
                      >separate visit in addition to the "complete H&P" for an annual exam, either
                      >to the patient or the payer.
                      >
                      >Jo Ann S
                      >
                      >
                      >
                      >At 03:18 PM 8/1/2004, you wrote:
                      > >Jo Ann, I am sorry if I am sounding redundent. I am new to the world of
                      > >coding. I have been working at this facility to get the needed
                      > >experience. I am like an old dog with a bone when it comes to something I
                      > >don't quite understand and I see the coders at the facility all coding
                      > >differently and know one is giving me good answers as to why they are
                      > >doing what they are when coding this situation. Some of the coders code
                      > >all ICD-9-CM codes for the chronic conditions along with the CPT code for
                      > >level of E&M and the appropriate CPT code for annual exam with the
                      > >modifier 25. Then there are those that just leave off the chronic
                      > >condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam
                      > >and the CPT code for appropriate annual exam. I just believe that there
                      > >is only one correct way to give all of the appropriate ICD-9-CM codes and
                      > >CPT codes no matter who the insurance is through if there is any. Am I
                      > >wrong in believeing that you code all ICD-9-CM codes for all lisited
                      > > chronic conditions and if there are any new acute conditions at the
                      > > visit with the V code for the exam, and the appropriate CPT annual exam
                      > > code with modifier 25 and then the CPT level for E&M for that visit. And
                      > > then what correct order of sequencing is there for this visit? Sorry I
                      > > am long winded.
                      > >
                      > >
                      > >Jo Ann Steigerwald wrote:
                      > >First of all, it sounds like you are referring to diagnosis codes, not CPT
                      > >codes. The chronic condition codes should, of course, be used with the
                      > >"medically necessary" portion E/M code.
                      > >
                      > >If the patient does NOT have Medicare, the issue becomes how much work was
                      > >actually done that would NOT have been done with a routine annual exam? In
                      > >the E/M's I've reviewed for this specific issue, most of them did not have
                      > >appreciable amounts of work over and above the work one would expect to see
                      > >for a "routine annual exam" unless the patient presented with an acute, new
                      > >onset condition of signicance. Because many (not all but many) patients DO
                      > >have coverage for annual exams, "spliting the visit" is not as critical
                      > >for those patients, and for the most part, if you attempt to charge out a
                      > >second visit on the same date of service, it will be denied by the payer,
                      > >or the allowed amount for the preventive medicine service is just
                      > >artitrarily split into two payments for the two services.
                      > >
                      > >IMO, except in unusual circumstances, what you will collect is generally
                      > >not worth the extra work for non-Medicare patients.
                      > >
                      > >What makes it worhwhile (although still a lot of work) in Medicare patients
                      > >is that physicians for the most part will go ahead and "do" annual complete
                      > >exams on Medicare patients anyway (coverage not=withstanding) and the
                      > >billers/coders are left with either falsely billing the entire service to
                      > >Medicare, or splitting the visit and billing the appropriate portion to the
                      > >patient. This avoid, at least, billing the patient for the entire amount
                      > >of a preventive medicine visit, something most physicians don't want to do.
                      > >
                      > >Jo Ann S
                      > >
                      > >At 02:45 PM 8/1/2004, you wrote:
                      > > >So when coding for annual exam and an E&M at the same time you would list
                      > > >all chronic codes with any current dx codes for the visit. The billing
                      > > >department would then take care of only billing for the chronic conditions
                      > > >and any other conditions that are found at the time of the encounter not
                      > > >the annual visit when billing Medicare. Now what is done when the pt is
                      > > >does not have Medicare? All chronic conditions are coded along with any
                      > > >other conditions found during the encounter. You would also code for the
                      > > >annual exam correct with the modifier 25 and the level of E&M. From the
                      > > >coding stand point I want to know that I am coding per guidelines, not
                      > > >just for the biller. They will subtract what needs to be when billing for
                      > > >Medicare. My biggest problem besides understanding the big picture is
                      > > >knowing that my coding is correct for this type of situation. There are
                      > > >five other coders in the facility whom just code, and know one seems to be
                      > > >consistant with what they are coding when it
                      > > > comes to preventative and E&M coding during the same encounter. Thank
                      > > > you very much.
                      > > >
                      > > >Jo Ann Steigerwald wrote:Exactly - for Medicare
                      > > >patients because Medicare doesn't cover preventive
                      > > >medicine visits...so this allows you to bill Medicare for the "medically
                      > > >necessary" portion of the visit that you'd need to do anyway, and only
                      > bill
                      > > >the patient for the true amount that Medicare will not pay - the annual
                      > > >screening exam portion of the visit.
                      > > >
                      > > >The issue isn't whether the conditions are "stable" or not - its the
                      > > >"medically necessary" portion of the visit that you have to do to manage
                      > > >the aptient's condition, and establishing that they are "stable" (and thus
                      > > >any current medications etc are adequate at this time) is part of the
                      > > >medically necessary portion of the visit.
                      > > >
                      > > >Medicare won't allow you to charge for both visits because you'd be
                      > > >getting paid twice for the same visit....but they will pick up part of the
                      > > >charges. Needless to say, this is a different situation from non-Medicare
                      > > >patients who are likely to have preventive medicine coverage.
                      > > >
                      > > >Jo Ann S
                      > > >
                      > > >
                      > > >
                      > > >At 12:46 PM 8/1/2004, you wrote:
                      > > > >If I am understanding your answer correctly then: the chronic conditions
                      > > > >are subtarcted from the other part of the exam which is the preventative
                      > > > >portion, and that would reduce the amount that you would get for the
                      > > > >annual visit. I am just a coder and I am trying to get the big picture
                      > > > >here. I am just starting to learn the actual billing part. So from a
                      > > > >coders side would you still code the chronic conditions whether they are
                      > > > >stable or not, and also the preventative code if it is an annual visit
                      > > > >with the modifier 25? I really appreciate all of the advice and help for
                      > > > >everyone on this group. Thank you.
                      > > > >
                      > > > >Jo Ann Steigerwald wrote:I was referring
                      > > > >specifically to Medicare in my post; for Medicare patients,
                      > > > >you must subtract the "covered" visit from the noncovered service, and
                      > > your
                      > > > >total charge for the office services cannot exceed your "regular"
                      > > > >preventive medicine visit charge.
                      > > > >
                      > > > >Jo Ann S
                      > > > >
                      > > > >At 10:13 AM 7/31/2004, you wrote:
                      > > > > >I usually code both the preventative code and the office visit code,
                      > > some
                      > > > > >insurances pay both, others I have to appeal and I have the providers
                      > > > > >clearly document that add'l problems were discussed during the
                      > exam. Is
                      > > > > >that right?
                      > > > > >
                      > > > > >Kristina Creech
                      > > > > >M.R.S. Inc
                      > > > > >Mobile 919-291-8449
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                      > > > > >
                      > > > > >
                      > > > > > > [Original Message]
                      > > > > > > From: Jo Ann Steigerwald
                      > > > > > > To:
                      > > > > > > Date: 07/31/2004 12:57:24 AM
                      > > > > > > Subject: Re: [CRN-L] Preventative and E&M services
                      > > > > > >
                      > > > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                      > > > > >decision
                      > > > > > > making and "count" any portions that would have been done anyway
                      > > > (without
                      > > > > > > an annual exam) based on the patient's presenting health
                      > > conditions; in
                      > > > > > > other words, if the patient is coming in for rechecks at two or
                      > three
                      > > > > >month
                      > > > > > > intervals (not unusual for patients with that list of medical
                      > > > problems),
                      > > > > > > what portions of the service are done "anyway".
                      > > > > > >
                      > > > > > > The "extra" ones are the preventive medicine exam portion, the
                      > > portions
                      > > > > >of
                      > > > > > > the exam that are not "medically necessary" at this time based
                      > on the
                      > > > > > > patient's prsenting conditions. So what you are looking at is
                      > if the
                      > > > > > > patient came "only" for the known conditions for medication
                      > > refills for
                      > > > > > > example, what portions of the exam would need to be done.
                      > > > > > >
                      > > > > > > For example, in the first patient shown in your note, the "eye"
                      > > exam is
                      > > > > > > related to listed conditions, but ENT was probably not related to
                      > > > any of
                      > > > > > > those. The neck, heart and lungs are clearly done for known
                      > > conditions,
                      > > > > >as
                      > > > > > > is the abdomen, probably the extremities and skin. genital exam
                      > > > would be
                      > > > > > > "necessary" in this patient because of possible prostate disease
                      > > > > >(nocturia)
                      > > > > > > (which is NOT leaving a lot for preventive medicine).
                      > > > > > >
                      > > > > > > Also, do keep in mind that when you charge "two" visits, you are
                      > > > actually
                      > > > > > > subtracting the charges for the "medically necessary" visit
                      > from your
                      > > > > > > standard charge for the preventive medicne service, and billing the
                      > > > > >patient
                      > > > > > > the difference between the two (plus appropriate copay and
                      > > deductible;
                      > > > > >you
                      > > > > > > aren't actually charging out two complete visits.
                      > > > > > >
                      > > > > > > Jo Ann S
                      > > > > > >
                      > > > > > >
                      > > > > > > At 10:43 PM 7/30/2004, you wrote:
                      > > > > > > >Could someone explain to me how to code an annual exam for
                      > patients
                      > > > > > > >that have chronic conditions that may or may not be stable
                      > during an
                      > > > > > > >annual exam.
                      > > > > > > >Example 1: 65 year old patient is being seen for his annual exam
                      > > > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I
                      > used
                      > > > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                      > > > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg.
                      > > 99397-
                      > > > > > > >25 for annual exam and 99213 for the E&M level.
                      > > > > > > >Example 2: 74 year old patient is being seen for his annual exam
                      > > > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the
                      > V70.0
                      > > > > > > >for the annual exam and the 99397 for the visit.
                      > > > > > > >No one seems to be able to explain to me how to code a
                      > preventative
                      > > > > > > >and what seems to be an E&M level at the same time. I thought that
                      > > > > > > >chronic conditions should be coded during an annual exam even if
                      > > they
                      > > > > > > >are stable, because they affect the patients care and there are
                      > > > > > > >prescriptions to refill for these conditions. Most of the patients
                      > > > > > > >that are seen in the facility that I am at have quite a few
                      > chronic
                      > > > > > > >conditions. If this was a case of a younger patient coming in for
                      > > > > > > >there annual exam that is allowed by their insurance once a year I
                      > > > > > > >could see coding just the annual exam.
                      > > > > > > >Thank you to everyone in advance.
                      > > > > > > >
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                    • Bloom Viola
                      Thank you Jo Ann. I am going to share what you have told me tomorrow at work. I may be back with some more questions after discussing this with the other
                      Message 10 of 17 , Aug 1, 2004
                        Thank you Jo Ann. I am going to share what you have told me tomorrow at work. I may be back with some more questions after discussing this with the other coders. Again, thank you.

                        Jo Ann Steigerwald <jsteiger@...> wrote:Generally, you also see system-related ROS and past history or current
                        history that addresses those conditions; you'd also see items in the
                        physical exam related to the systems....putting all of that together, the
                        physician has addressed the concerns.




                        At 04:44 PM 8/1/2004, you wrote:
                        >Thank you, you have been so helpful. Now on to the documentation for the
                        >preventative and E&M visit. The several physicians at this facility Iist
                        >all of the chronic conditions even if they don't directly talk about
                        >them. I code all of these because he has them in his dx list. I am
                        >assuming this is ok since he put them on his list of dxs. I always code
                        >certain chronic conditions such as diabetes, HTN, CAD, COPD,
                        >Hyperlimpidemia etc. As long as the doctor has them on his dx list even
                        >though he doesn't directly address them is it correct to code them like I
                        >have been doing? I am talking for E&M visits and preventative.
                        >
                        >Jo Ann Steigerwald wrote:If you are using a
                        >preventive medicine code, the V could should go out
                        >first (as the "reason" for the visit) on all payers...Some payers will not
                        >accept a preventive medicine code if it has additional diagnosis codes
                        >attached. Correctly done, you should sequence the "first" diagnosis as the
                        >one that reflects the "reason" the patient scheduled the visit....in this
                        >case a V code, and include any conditions that were addressed during this
                        >visit as secondary codes. (Address may be treated directly, or those
                        >conditions documented as impacting the outcome in some way, such as a child
                        >presenting with an URI who is asthmatic: URI first, asthma second, unless
                        >the chld presented for problems with the asthma because there is an
                        >underlying URI).
                        >
                        >In the end, you must consider the charges being submitted for payment and
                        >the payer requirements; if the patient has preventive medicine coverage,
                        >and presented for an "annual exam" and the payer will not accept additional
                        >codes with the preventive medicne codes, use only the V-code; use additonal
                        >codes if the payer will accept them.
                        >
                        >Most likely the variations you are seeing are at least in part due to
                        >varying requirements by payers, and there is no way to get around complying
                        >with payer requirements if you are going to get the claims paid.
                        >
                        >The error that I see most commonly is leaving off secondary diagnoses
                        >altogether when a payer will accept them (and in cases collects the
                        >information), and includng chronic and past history codes when there is
                        >nothing in the documentation to show that the condition was addressed.
                        >
                        >Another error is charging an "separate" visit when what was done was
                        >actually a prescription refill.....The doctor has reviewed current meds as
                        >part of past history, and while there is some "decision making" involved in
                        >writing an RX, that alone is probably not enough to justify an entirely
                        >separate visit in addition to the "complete H&P" for an annual exam, either
                        >to the patient or the payer.
                        >
                        >Jo Ann S
                        >
                        >
                        >
                        >At 03:18 PM 8/1/2004, you wrote:
                        > >Jo Ann, I am sorry if I am sounding redundent. I am new to the world of
                        > >coding. I have been working at this facility to get the needed
                        > >experience. I am like an old dog with a bone when it comes to something I
                        > >don't quite understand and I see the coders at the facility all coding
                        > >differently and know one is giving me good answers as to why they are
                        > >doing what they are when coding this situation. Some of the coders code
                        > >all ICD-9-CM codes for the chronic conditions along with the CPT code for
                        > >level of E&M and the appropriate CPT code for annual exam with the
                        > >modifier 25. Then there are those that just leave off the chronic
                        > >condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam
                        > >and the CPT code for appropriate annual exam. I just believe that there
                        > >is only one correct way to give all of the appropriate ICD-9-CM codes and
                        > >CPT codes no matter who the insurance is through if there is any. Am I
                        > >wrong in believeing that you code all ICD-9-CM codes for all lisited
                        > > chronic conditions and if there are any new acute conditions at the
                        > > visit with the V code for the exam, and the appropriate CPT annual exam
                        > > code with modifier 25 and then the CPT level for E&M for that visit. And
                        > > then what correct order of sequencing is there for this visit? Sorry I
                        > > am long winded.
                        > >
                        > >
                        > >Jo Ann Steigerwald wrote:
                        > >First of all, it sounds like you are referring to diagnosis codes, not CPT
                        > >codes. The chronic condition codes should, of course, be used with the
                        > >"medically necessary" portion E/M code.
                        > >
                        > >If the patient does NOT have Medicare, the issue becomes how much work was
                        > >actually done that would NOT have been done with a routine annual exam? In
                        > >the E/M's I've reviewed for this specific issue, most of them did not have
                        > >appreciable amounts of work over and above the work one would expect to see
                        > >for a "routine annual exam" unless the patient presented with an acute, new
                        > >onset condition of signicance. Because many (not all but many) patients DO
                        > >have coverage for annual exams, "spliting the visit" is not as critical
                        > >for those patients, and for the most part, if you attempt to charge out a
                        > >second visit on the same date of service, it will be denied by the payer,
                        > >or the allowed amount for the preventive medicine service is just
                        > >artitrarily split into two payments for the two services.
                        > >
                        > >IMO, except in unusual circumstances, what you will collect is generally
                        > >not worth the extra work for non-Medicare patients.
                        > >
                        > >What makes it worhwhile (although still a lot of work) in Medicare patients
                        > >is that physicians for the most part will go ahead and "do" annual complete
                        > >exams on Medicare patients anyway (coverage not=withstanding) and the
                        > >billers/coders are left with either falsely billing the entire service to
                        > >Medicare, or splitting the visit and billing the appropriate portion to the
                        > >patient. This avoid, at least, billing the patient for the entire amount
                        > >of a preventive medicine visit, something most physicians don't want to do.
                        > >
                        > >Jo Ann S
                        > >
                        > >At 02:45 PM 8/1/2004, you wrote:
                        > > >So when coding for annual exam and an E&M at the same time you would list
                        > > >all chronic codes with any current dx codes for the visit. The billing
                        > > >department would then take care of only billing for the chronic conditions
                        > > >and any other conditions that are found at the time of the encounter not
                        > > >the annual visit when billing Medicare. Now what is done when the pt is
                        > > >does not have Medicare? All chronic conditions are coded along with any
                        > > >other conditions found during the encounter. You would also code for the
                        > > >annual exam correct with the modifier 25 and the level of E&M. From the
                        > > >coding stand point I want to know that I am coding per guidelines, not
                        > > >just for the biller. They will subtract what needs to be when billing for
                        > > >Medicare. My biggest problem besides understanding the big picture is
                        > > >knowing that my coding is correct for this type of situation. There are
                        > > >five other coders in the facility whom just code, and know one seems to be
                        > > >consistant with what they are coding when it
                        > > > comes to preventative and E&M coding during the same encounter. Thank
                        > > > you very much.
                        > > >
                        > > >Jo Ann Steigerwald wrote:Exactly - for Medicare
                        > > >patients because Medicare doesn't cover preventive
                        > > >medicine visits...so this allows you to bill Medicare for the "medically
                        > > >necessary" portion of the visit that you'd need to do anyway, and only
                        > bill
                        > > >the patient for the true amount that Medicare will not pay - the annual
                        > > >screening exam portion of the visit.
                        > > >
                        > > >The issue isn't whether the conditions are "stable" or not - its the
                        > > >"medically necessary" portion of the visit that you have to do to manage
                        > > >the aptient's condition, and establishing that they are "stable" (and thus
                        > > >any current medications etc are adequate at this time) is part of the
                        > > >medically necessary portion of the visit.
                        > > >
                        > > >Medicare won't allow you to charge for both visits because you'd be
                        > > >getting paid twice for the same visit....but they will pick up part of the
                        > > >charges. Needless to say, this is a different situation from non-Medicare
                        > > >patients who are likely to have preventive medicine coverage.
                        > > >
                        > > >Jo Ann S
                        > > >
                        > > >
                        > > >
                        > > >At 12:46 PM 8/1/2004, you wrote:
                        > > > >If I am understanding your answer correctly then: the chronic conditions
                        > > > >are subtarcted from the other part of the exam which is the preventative
                        > > > >portion, and that would reduce the amount that you would get for the
                        > > > >annual visit. I am just a coder and I am trying to get the big picture
                        > > > >here. I am just starting to learn the actual billing part. So from a
                        > > > >coders side would you still code the chronic conditions whether they are
                        > > > >stable or not, and also the preventative code if it is an annual visit
                        > > > >with the modifier 25? I really appreciate all of the advice and help for
                        > > > >everyone on this group. Thank you.
                        > > > >
                        > > > >Jo Ann Steigerwald wrote:I was referring
                        > > > >specifically to Medicare in my post; for Medicare patients,
                        > > > >you must subtract the "covered" visit from the noncovered service, and
                        > > your
                        > > > >total charge for the office services cannot exceed your "regular"
                        > > > >preventive medicine visit charge.
                        > > > >
                        > > > >Jo Ann S
                        > > > >
                        > > > >At 10:13 AM 7/31/2004, you wrote:
                        > > > > >I usually code both the preventative code and the office visit code,
                        > > some
                        > > > > >insurances pay both, others I have to appeal and I have the providers
                        > > > > >clearly document that add'l problems were discussed during the
                        > exam. Is
                        > > > > >that right?
                        > > > > >
                        > > > > >Kristina Creech
                        > > > > >M.R.S. Inc
                        > > > > >Mobile 919-291-8449
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                        > > > > >
                        > > > > >
                        > > > > > > [Original Message]
                        > > > > > > From: Jo Ann Steigerwald
                        > > > > > > To:
                        > > > > > > Date: 07/31/2004 12:57:24 AM
                        > > > > > > Subject: Re: [CRN-L] Preventative and E&M services
                        > > > > > >
                        > > > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                        > > > > >decision
                        > > > > > > making and "count" any portions that would have been done anyway
                        > > > (without
                        > > > > > > an annual exam) based on the patient's presenting health
                        > > conditions; in
                        > > > > > > other words, if the patient is coming in for rechecks at two or
                        > three
                        > > > > >month
                        > > > > > > intervals (not unusual for patients with that list of medical
                        > > > problems),
                        > > > > > > what portions of the service are done "anyway".
                        > > > > > >
                        > > > > > > The "extra" ones are the preventive medicine exam portion, the
                        > > portions
                        > > > > >of
                        > > > > > > the exam that are not "medically necessary" at this time based
                        > on the
                        > > > > > > patient's prsenting conditions. So what you are looking at is
                        > if the
                        > > > > > > patient came "only" for the known conditions for medication
                        > > refills for
                        > > > > > > example, what portions of the exam would need to be done.
                        > > > > > >
                        > > > > > > For example, in the first patient shown in your note, the "eye"
                        > > exam is
                        > > > > > > related to listed conditions, but ENT was probably not related to
                        > > > any of
                        > > > > > > those. The neck, heart and lungs are clearly done for known
                        > > conditions,
                        > > > > >as
                        > > > > > > is the abdomen, probably the extremities and skin. genital exam
                        > > > would be
                        > > > > > > "necessary" in this patient because of possible prostate disease
                        > > > > >(nocturia)
                        > > > > > > (which is NOT leaving a lot for preventive medicine).
                        > > > > > >
                        > > > > > > Also, do keep in mind that when you charge "two" visits, you are
                        > > > actually
                        > > > > > > subtracting the charges for the "medically necessary" visit
                        > from your
                        > > > > > > standard charge for the preventive medicne service, and billing the
                        > > > > >patient
                        > > > > > > the difference between the two (plus appropriate copay and
                        > > deductible;
                        > > > > >you
                        > > > > > > aren't actually charging out two complete visits.
                        > > > > > >
                        > > > > > > Jo Ann S
                        > > > > > >
                        > > > > > >
                        > > > > > > At 10:43 PM 7/30/2004, you wrote:
                        > > > > > > >Could someone explain to me how to code an annual exam for
                        > patients
                        > > > > > > >that have chronic conditions that may or may not be stable
                        > during an
                        > > > > > > >annual exam.
                        > > > > > > >Example 1: 65 year old patient is being seen for his annual exam
                        > > > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I
                        > used
                        > > > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                        > > > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg.
                        > > 99397-
                        > > > > > > >25 for annual exam and 99213 for the E&M level.
                        > > > > > > >Example 2: 74 year old patient is being seen for his annual exam
                        > > > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the
                        > V70.0
                        > > > > > > >for the annual exam and the 99397 for the visit.
                        > > > > > > >No one seems to be able to explain to me how to code a
                        > preventative
                        > > > > > > >and what seems to be an E&M level at the same time. I thought that
                        > > > > > > >chronic conditions should be coded during an annual exam even if
                        > > they
                        > > > > > > >are stable, because they affect the patients care and there are
                        > > > > > > >prescriptions to refill for these conditions. Most of the patients
                        > > > > > > >that are seen in the facility that I am at have quite a few
                        > chronic
                        > > > > > > >conditions. If this was a case of a younger patient coming in for
                        > > > > > > >there annual exam that is allowed by their insurance once a year I
                        > > > > > > >could see coding just the annual exam.
                        > > > > > > >Thank you to everyone in advance.
                        > > > > > > >
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                      • Jo Ann Steigerwald
                        You re welcome.... ... [Non-text portions of this message have been removed]
                        Message 11 of 17 , Aug 1, 2004
                          You're welcome....

                          At 05:43 PM 8/1/2004, you wrote:
                          >Thank you Jo Ann. I am going to share what you have told me tomorrow at
                          >work. I may be back with some more questions after discussing this with
                          >the other coders. Again, thank you.
                          >
                          >Jo Ann Steigerwald <jsteiger@...> wrote:Generally, you also see
                          >system-related ROS and past history or current
                          >history that addresses those conditions; you'd also see items in the
                          >physical exam related to the systems....putting all of that together, the
                          >physician has addressed the concerns.
                          >
                          >
                          >
                          >
                          >At 04:44 PM 8/1/2004, you wrote:
                          > >Thank you, you have been so helpful. Now on to the documentation for the
                          > >preventative and E&M visit. The several physicians at this facility Iist
                          > >all of the chronic conditions even if they don't directly talk about
                          > >them. I code all of these because he has them in his dx list. I am
                          > >assuming this is ok since he put them on his list of dxs. I always code
                          > >certain chronic conditions such as diabetes, HTN, CAD, COPD,
                          > >Hyperlimpidemia etc. As long as the doctor has them on his dx list even
                          > >though he doesn't directly address them is it correct to code them like I
                          > >have been doing? I am talking for E&M visits and preventative.
                          > >
                          > >Jo Ann Steigerwald wrote:If you are using a
                          > >preventive medicine code, the V could should go out
                          > >first (as the "reason" for the visit) on all payers...Some payers will not
                          > >accept a preventive medicine code if it has additional diagnosis codes
                          > >attached. Correctly done, you should sequence the "first" diagnosis as the
                          > >one that reflects the "reason" the patient scheduled the visit....in this
                          > >case a V code, and include any conditions that were addressed during this
                          > >visit as secondary codes. (Address may be treated directly, or those
                          > >conditions documented as impacting the outcome in some way, such as a child
                          > >presenting with an URI who is asthmatic: URI first, asthma second, unless
                          > >the chld presented for problems with the asthma because there is an
                          > >underlying URI).
                          > >
                          > >In the end, you must consider the charges being submitted for payment and
                          > >the payer requirements; if the patient has preventive medicine coverage,
                          > >and presented for an "annual exam" and the payer will not accept additional
                          > >codes with the preventive medicne codes, use only the V-code; use additonal
                          > >codes if the payer will accept them.
                          > >
                          > >Most likely the variations you are seeing are at least in part due to
                          > >varying requirements by payers, and there is no way to get around complying
                          > >with payer requirements if you are going to get the claims paid.
                          > >
                          > >The error that I see most commonly is leaving off secondary diagnoses
                          > >altogether when a payer will accept them (and in cases collects the
                          > >information), and includng chronic and past history codes when there is
                          > >nothing in the documentation to show that the condition was addressed.
                          > >
                          > >Another error is charging an "separate" visit when what was done was
                          > >actually a prescription refill.....The doctor has reviewed current meds as
                          > >part of past history, and while there is some "decision making" involved in
                          > >writing an RX, that alone is probably not enough to justify an entirely
                          > >separate visit in addition to the "complete H&P" for an annual exam, either
                          > >to the patient or the payer.
                          > >
                          > >Jo Ann S
                          > >
                          > >
                          > >
                          > >At 03:18 PM 8/1/2004, you wrote:
                          > > >Jo Ann, I am sorry if I am sounding redundent. I am new to the world of
                          > > >coding. I have been working at this facility to get the needed
                          > > >experience. I am like an old dog with a bone when it comes to something I
                          > > >don't quite understand and I see the coders at the facility all coding
                          > > >differently and know one is giving me good answers as to why they are
                          > > >doing what they are when coding this situation. Some of the coders code
                          > > >all ICD-9-CM codes for the chronic conditions along with the CPT code for
                          > > >level of E&M and the appropriate CPT code for annual exam with the
                          > > >modifier 25. Then there are those that just leave off the chronic
                          > > >condition ICD-9-CM codes and only code the ICD-9-CM V code for annual exam
                          > > >and the CPT code for appropriate annual exam. I just believe that there
                          > > >is only one correct way to give all of the appropriate ICD-9-CM codes and
                          > > >CPT codes no matter who the insurance is through if there is any. Am I
                          > > >wrong in believeing that you code all ICD-9-CM codes for all lisited
                          > > > chronic conditions and if there are any new acute conditions at the
                          > > > visit with the V code for the exam, and the appropriate CPT annual exam
                          > > > code with modifier 25 and then the CPT level for E&M for that visit. And
                          > > > then what correct order of sequencing is there for this visit? Sorry I
                          > > > am long winded.
                          > > >
                          > > >
                          > > >Jo Ann Steigerwald wrote:
                          > > >First of all, it sounds like you are referring to diagnosis codes, not CPT
                          > > >codes. The chronic condition codes should, of course, be used with the
                          > > >"medically necessary" portion E/M code.
                          > > >
                          > > >If the patient does NOT have Medicare, the issue becomes how much work was
                          > > >actually done that would NOT have been done with a routine annual exam? In
                          > > >the E/M's I've reviewed for this specific issue, most of them did not have
                          > > >appreciable amounts of work over and above the work one would expect
                          > to see
                          > > >for a "routine annual exam" unless the patient presented with an
                          > acute, new
                          > > >onset condition of signicance. Because many (not all but many) patients DO
                          > > >have coverage for annual exams, "spliting the visit" is not as critical
                          > > >for those patients, and for the most part, if you attempt to charge out a
                          > > >second visit on the same date of service, it will be denied by the payer,
                          > > >or the allowed amount for the preventive medicine service is just
                          > > >artitrarily split into two payments for the two services.
                          > > >
                          > > >IMO, except in unusual circumstances, what you will collect is generally
                          > > >not worth the extra work for non-Medicare patients.
                          > > >
                          > > >What makes it worhwhile (although still a lot of work) in Medicare
                          > patients
                          > > >is that physicians for the most part will go ahead and "do" annual
                          > complete
                          > > >exams on Medicare patients anyway (coverage not=withstanding) and the
                          > > >billers/coders are left with either falsely billing the entire service to
                          > > >Medicare, or splitting the visit and billing the appropriate portion
                          > to the
                          > > >patient. This avoid, at least, billing the patient for the entire amount
                          > > >of a preventive medicine visit, something most physicians don't want
                          > to do.
                          > > >
                          > > >Jo Ann S
                          > > >
                          > > >At 02:45 PM 8/1/2004, you wrote:
                          > > > >So when coding for annual exam and an E&M at the same time you would
                          > list
                          > > > >all chronic codes with any current dx codes for the visit. The billing
                          > > > >department would then take care of only billing for the chronic
                          > conditions
                          > > > >and any other conditions that are found at the time of the encounter not
                          > > > >the annual visit when billing Medicare. Now what is done when the pt is
                          > > > >does not have Medicare? All chronic conditions are coded along with any
                          > > > >other conditions found during the encounter. You would also code for the
                          > > > >annual exam correct with the modifier 25 and the level of E&M. From the
                          > > > >coding stand point I want to know that I am coding per guidelines, not
                          > > > >just for the biller. They will subtract what needs to be when
                          > billing for
                          > > > >Medicare. My biggest problem besides understanding the big picture is
                          > > > >knowing that my coding is correct for this type of situation. There are
                          > > > >five other coders in the facility whom just code, and know one seems
                          > to be
                          > > > >consistant with what they are coding when it
                          > > > > comes to preventative and E&M coding during the same encounter. Thank
                          > > > > you very much.
                          > > > >
                          > > > >Jo Ann Steigerwald wrote:Exactly - for Medicare
                          > > > >patients because Medicare doesn't cover preventive
                          > > > >medicine visits...so this allows you to bill Medicare for the "medically
                          > > > >necessary" portion of the visit that you'd need to do anyway, and only
                          > > bill
                          > > > >the patient for the true amount that Medicare will not pay - the annual
                          > > > >screening exam portion of the visit.
                          > > > >
                          > > > >The issue isn't whether the conditions are "stable" or not - its the
                          > > > >"medically necessary" portion of the visit that you have to do to manage
                          > > > >the aptient's condition, and establishing that they are "stable"
                          > (and thus
                          > > > >any current medications etc are adequate at this time) is part of the
                          > > > >medically necessary portion of the visit.
                          > > > >
                          > > > >Medicare won't allow you to charge for both visits because you'd be
                          > > > >getting paid twice for the same visit....but they will pick up part
                          > of the
                          > > > >charges. Needless to say, this is a different situation from
                          > non-Medicare
                          > > > >patients who are likely to have preventive medicine coverage.
                          > > > >
                          > > > >Jo Ann S
                          > > > >
                          > > > >
                          > > > >
                          > > > >At 12:46 PM 8/1/2004, you wrote:
                          > > > > >If I am understanding your answer correctly then: the chronic
                          > conditions
                          > > > > >are subtarcted from the other part of the exam which is the
                          > preventative
                          > > > > >portion, and that would reduce the amount that you would get for the
                          > > > > >annual visit. I am just a coder and I am trying to get the big picture
                          > > > > >here. I am just starting to learn the actual billing part. So from a
                          > > > > >coders side would you still code the chronic conditions whether
                          > they are
                          > > > > >stable or not, and also the preventative code if it is an annual visit
                          > > > > >with the modifier 25? I really appreciate all of the advice and
                          > help for
                          > > > > >everyone on this group. Thank you.
                          > > > > >
                          > > > > >Jo Ann Steigerwald wrote:I was referring
                          > > > > >specifically to Medicare in my post; for Medicare patients,
                          > > > > >you must subtract the "covered" visit from the noncovered service, and
                          > > > your
                          > > > > >total charge for the office services cannot exceed your "regular"
                          > > > > >preventive medicine visit charge.
                          > > > > >
                          > > > > >Jo Ann S
                          > > > > >
                          > > > > >At 10:13 AM 7/31/2004, you wrote:
                          > > > > > >I usually code both the preventative code and the office visit code,
                          > > > some
                          > > > > > >insurances pay both, others I have to appeal and I have the
                          > providers
                          > > > > > >clearly document that add'l problems were discussed during the
                          > > exam. Is
                          > > > > > >that right?
                          > > > > > >
                          > > > > > >Kristina Creech
                          > > > > > >M.R.S. Inc
                          > > > > > >Mobile 919-291-8449
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                          > > > > > >
                          > > > > > > > [Original Message]
                          > > > > > > > From: Jo Ann Steigerwald
                          > > > > > > > To:
                          > > > > > > > Date: 07/31/2004 12:57:24 AM
                          > > > > > > > Subject: Re: [CRN-L] Preventative and E&M services
                          > > > > > > >
                          > > > > > > > Look at it this way: go through the history, PFSH, ROS, exam and
                          > > > > > >decision
                          > > > > > > > making and "count" any portions that would have been done anyway
                          > > > > (without
                          > > > > > > > an annual exam) based on the patient's presenting health
                          > > > conditions; in
                          > > > > > > > other words, if the patient is coming in for rechecks at two or
                          > > three
                          > > > > > >month
                          > > > > > > > intervals (not unusual for patients with that list of medical
                          > > > > problems),
                          > > > > > > > what portions of the service are done "anyway".
                          > > > > > > >
                          > > > > > > > The "extra" ones are the preventive medicine exam portion, the
                          > > > portions
                          > > > > > >of
                          > > > > > > > the exam that are not "medically necessary" at this time based
                          > > on the
                          > > > > > > > patient's prsenting conditions. So what you are looking at is
                          > > if the
                          > > > > > > > patient came "only" for the known conditions for medication
                          > > > refills for
                          > > > > > > > example, what portions of the exam would need to be done.
                          > > > > > > >
                          > > > > > > > For example, in the first patient shown in your note, the "eye"
                          > > > exam is
                          > > > > > > > related to listed conditions, but ENT was probably not related to
                          > > > > any of
                          > > > > > > > those. The neck, heart and lungs are clearly done for known
                          > > > conditions,
                          > > > > > >as
                          > > > > > > > is the abdomen, probably the extremities and skin. genital exam
                          > > > > would be
                          > > > > > > > "necessary" in this patient because of possible prostate disease
                          > > > > > >(nocturia)
                          > > > > > > > (which is NOT leaving a lot for preventive medicine).
                          > > > > > > >
                          > > > > > > > Also, do keep in mind that when you charge "two" visits, you are
                          > > > > actually
                          > > > > > > > subtracting the charges for the "medically necessary" visit
                          > > from your
                          > > > > > > > standard charge for the preventive medicne service, and
                          > billing the
                          > > > > > >patient
                          > > > > > > > the difference between the two (plus appropriate copay and
                          > > > deductible;
                          > > > > > >you
                          > > > > > > > aren't actually charging out two complete visits.
                          > > > > > > >
                          > > > > > > > Jo Ann S
                          > > > > > > >
                          > > > > > > >
                          > > > > > > > At 10:43 PM 7/30/2004, you wrote:
                          > > > > > > > >Could someone explain to me how to code an annual exam for
                          > > patients
                          > > > > > > > >that have chronic conditions that may or may not be stable
                          > > during an
                          > > > > > > > >annual exam.
                          > > > > > > > >Example 1: 65 year old patient is being seen for his annual exam
                          > > > > > > > >with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I
                          > > used
                          > > > > > > > >V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for )
                          > > > > > > > >Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg.
                          > > > 99397-
                          > > > > > > > >25 for annual exam and 99213 for the E&M level.
                          > > > > > > > >Example 2: 74 year old patient is being seen for his annual exam
                          > > > > > > > >with HTN, CAD, Glaucoma, and COPD. I was told to only use the
                          > > V70.0
                          > > > > > > > >for the annual exam and the 99397 for the visit.
                          > > > > > > > >No one seems to be able to explain to me how to code a
                          > > preventative
                          > > > > > > > >and what seems to be an E&M level at the same time. I
                          > thought that
                          > > > > > > > >chronic conditions should be coded during an annual exam even if
                          > > > they
                          > > > > > > > >are stable, because they affect the patients care and there are
                          > > > > > > > >prescriptions to refill for these conditions. Most of the
                          > patients
                          > > > > > > > >that are seen in the facility that I am at have quite a few
                          > > chronic
                          > > > > > > > >conditions. If this was a case of a younger patient coming
                          > in for
                          > > > > > > > >there annual exam that is allowed by their insurance once a
                          > year I
                          > > > > > > > >could see coding just the annual exam.
                          > > > > > > > >Thank you to everyone in advance.
                          > > > > > > > >
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                        • Dianne Wilkinson
                          It is very common for primary care physicians to schedule an elderly person s annual physical on a date when the patient is coming in for the followup of
                          Message 12 of 17 , Aug 2, 2004
                            It is very common for primary care physicians to schedule an elderly
                            person's annual physical on a date when the patient is coming in for the
                            followup of chronic problems such as the ones you mentioned. Apart from the
                            preventive portion of the visit, there is generally some history that would
                            document the status of the chronic problems...what home sugars are running,
                            still tolerating BP meds, etc. As Jo Ann mentioned, the exam pertinent to
                            the chronic problems would be included; there might be labs, etc., ordered
                            as a part of the followup of the problems, and then in the plan, some
                            statement about continuing their meds the same or making an adjustment.
                            This certainly meets Medicare's criteria for what they call a "split care
                            visit", billing both the preventive and the problem-oriented E&M codes to
                            the level supported by the documentation. (I'd mention the G&Q codes here
                            if this were a full well woman exam on a Medicare patient.) Dianne.


                            -----Original Message-----
                            From: violasinbloom [mailto:violasinbloom@...]
                            Sent: Friday, July 30, 2004 10:44 PM
                            To: CRN-L@yahoogroups.com
                            Subject: [CRN-L] Preventative and E&M services


                            Could someone explain to me how to code an annual exam for patients
                            that have chronic conditions that may or may not be stable during an
                            annual exam.
                            Example 1: 65 year old patient is being seen for his annual exam
                            with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
                            V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for
                            Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
                            25 for annual exam and 99213 for the E&M level.
                            Example 2: 74 year old patient is being seen for his annual exam
                            with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
                            for the annual exam and the 99397 for the visit.
                            No one seems to be able to explain to me how to code a preventative
                            and what seems to be an E&M level at the same time. I thought that
                            chronic conditions should be coded during an annual exam even if they
                            are stable, because they affect the patients care and there are
                            prescriptions to refill for these conditions. Most of the patients
                            that are seen in the facility that I am at have quite a few chronic
                            conditions. If this was a case of a younger patient coming in for
                            there annual exam that is allowed by their insurance once a year I
                            could see coding just the annual exam.
                            Thank you to everyone in advance.



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                          • Bloom Viola
                            Thank you Dianne. Dianne Wilkinson wrote:It is very common for primary care physicians to schedule an elderly person s annual physical
                            Message 13 of 17 , Aug 4, 2004
                              Thank you Dianne.

                              Dianne Wilkinson <dbwilkinson@...> wrote:It is very common for primary care physicians to schedule an elderly
                              person's annual physical on a date when the patient is coming in for the
                              followup of chronic problems such as the ones you mentioned. Apart from the
                              preventive portion of the visit, there is generally some history that would
                              document the status of the chronic problems...what home sugars are running,
                              still tolerating BP meds, etc. As Jo Ann mentioned, the exam pertinent to
                              the chronic problems would be included; there might be labs, etc., ordered
                              as a part of the followup of the problems, and then in the plan, some
                              statement about continuing their meds the same or making an adjustment.
                              This certainly meets Medicare's criteria for what they call a "split care
                              visit", billing both the preventive and the problem-oriented E&M codes to
                              the level supported by the documentation. (I'd mention the G&Q codes here
                              if this were a full well woman exam on a Medicare patient.) Dianne.


                              -----Original Message-----
                              From: violasinbloom [mailto:violasinbloom@...]
                              Sent: Friday, July 30, 2004 10:44 PM
                              To: CRN-L@yahoogroups.com
                              Subject: [CRN-L] Preventative and E&M services


                              Could someone explain to me how to code an annual exam for patients
                              that have chronic conditions that may or may not be stable during an
                              annual exam.
                              Example 1: 65 year old patient is being seen for his annual exam
                              with COPD(stable), HTN, Nocturia, A-fib, and he is on Coreg. I used
                              V70.0 for annual exam, 496 for COPD, 401.1 for HTN, 788.43 for
                              Nocturia, 427.31 for A-fib, V58.61 for Long term use of Coreg. 99397-
                              25 for annual exam and 99213 for the E&M level.
                              Example 2: 74 year old patient is being seen for his annual exam
                              with HTN, CAD, Glaucoma, and COPD. I was told to only use the V70.0
                              for the annual exam and the 99397 for the visit.
                              No one seems to be able to explain to me how to code a preventative
                              and what seems to be an E&M level at the same time. I thought that
                              chronic conditions should be coded during an annual exam even if they
                              are stable, because they affect the patients care and there are
                              prescriptions to refill for these conditions. Most of the patients
                              that are seen in the facility that I am at have quite a few chronic
                              conditions. If this was a case of a younger patient coming in for
                              there annual exam that is allowed by their insurance once a year I
                              could see coding just the annual exam.
                              Thank you to everyone in advance.



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