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Wednesday Jan 18, 2017

What's in a Name? Annual Exam Jargon Causes Confusion

It is traditional to welcome the new year with health-related resolutions, which frequently lead patients to schedule a visit with their doctor for an annual exam.

Patients have long been encouraged to see their doctor once a year for a general checkup, but what once was easy, expected and often covered by insurance has, unfortunately, become confusing in our new era of health reform.

The problem is an overabundance of terms that mean similar things to patients but have vastly different definitions for payers. There are enough variations -- annual physical exam, comprehensive exam, general medical exam, gynecological exam, Medicare annual wellness exam, sports physical and well-child-exam -- to confuse not only patients but physicians and office staff.

Patients need to know what to expect, what to ask for and how often they should be seen.

Physicians need to know how to document and bill appropriately for services rendered.

Staff need to know how much time to schedule for each of the various exams and how to communicate the facts of split billing when necessary, and they must be aware that patient satisfaction will be affected if the latter issue isn't addressed properly.

Here is a look at the different types of exams and what patient services they are meant to include, along with some tips to ensure you get paid properly for the comprehensive care you provide.

Medicare Annual Wellness Visit
The annual wellness visit (G0438-G0439) and the initial preventive physical exam (G0402) are Medicare benefits. Both of these encounters require that height, weight, body mass index and blood pressure be assessed (the initial preventive physical exam also calls for vision screening), but no other physical exam component is required.

This often can be a point of contention between physicians and their patients, who incorrectly assume this is a head-to-toe annual exam. In reality, preventive exams -- as defined by CPT -- are statutorily excluded and not covered. If a patient chooses to receive a preventive examination, this does not need to be submitted to Medicare; the patient is financially responsible.

A more in-depth look at the annual wellness visit, including how to optimize revenue and improve quality, was recently included as a supplement to Family Practice Management.

Private Payers
General medical exams, annual physical exams and well-child exams are preventive medicine visits, and are typically reported with a CPT code ranging from 99381-99397. The specific code depends on whether the patient is new or established and also is based on the age of the patient. These services, per CPT, include "an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures."

Most private payers have covered these codes without any patient cost-sharing under the terms of the Patient Protection and Affordable Care Act (ACA). It's unclear how congressional attempts to repeal and replace the ACA will affect that coverage.

Comprehensive Exam
This term refers to the highest level of exam associated with evaluation and management (E/M) services. For problem-oriented E/M services, a comprehensive exam is a general multisystem exam or a complete examination of a single organ system, per CPT. Medicare's documentation guidelines(www.cms.gov) for E/M services provide significant detail on what constitutes a comprehensive exam. Preventive medicine E/M services also include a comprehensive exam, which is multisystem, but its extent is based on the patient's age and risk factors. Thus, a comprehensive exam for a preventive visit is not the same as one for a problem-oriented visit.

Things become potentially more complicated when a woman calls to schedule her "annual" appointment. Preventive screening recommendations for pelvic exams and Pap smears have changed significantly, yet many women still think they need an annual Pap and pelvic exam. Due to those changes in recommendations, many practices schedule differently for female preventive care visits with and without Pap smear and Pap-only visits, yet patients often don't know which type of visit they need when they call to schedule an appointment. If your office schedules differently for these various exams, it is important for your front desk staff to understand these recommendations when making the appointment so that they can allow for appropriate time and room resource scheduling.

Also keep in mind that some insurance plans will pay for a gynecological exam as well as a preventive physical exam. How can an insurance company tell the difference when the same CPT code represents both services? By the diagnosis code attached to the claim:  Z00.xx for a general adult medical exam or Z01.xx for a gynecological exam. Physicians should verify the patient has dual benefits if they want to separate the visits.


Billing for well-child visits can be an issue if frequency is not monitored closely. When a child who already has had a well-child visit presents a second time for a school, Scouts or sports physical,  the claim often will be denied. Parents will be upset when they receive a bill for $150 to $200 for what they thought was a covered service. One way this problem can be avoided is by charging a cash rate, payable at the time of the service, for the special circumstance physical. Practices can require the responsible party to sign a waiver acknowledging that a claim will not be filed.

Split Billing
The value of family medicine is our ability to care for the majority of conditions with which our patients present. Patients value our comprehensiveness and often think of our practices as one-stop shops. Gone are the days of "bring your laundry list of problems and we'll address them all at your annual exam under your preventive visit code."

Unfortunately, that expectation still exists for many patients. However, we are mandated to document and code separately for preventive service and other E/M codes and procedures. Split billing allows us to be appropriately reimbursed for the value we bring to patients when we provide these blended visits. But split billing can create confusion and frustration for patients.

When a physician sees a patient on the same date for a preventive service and a problem visit, CPT calls for appending the modifier -25 to the problem visit code (typically 99201-99205 or 99212-99215) and billing the preventive service additionally. However, this is not cut-and-dried in the real world. Every insurance company has its own rules. Even within a parent insurance company, the child policy (usually by employer or group coverage) will specify even further if they will impose restrictions on allowing for a problem and a preventive visit on the same day. One tip is to construct a grid for your top payers showing which payers allow a preventive visit and a problem visit on the same day -- and which don't -- and post that information in every exam room.

It is up to the entire staff, physicians included, to inform the patient of the potential for financial liability in the form of a deductible or copay if significant medical problems are also addressed on the day of a preventive exam.

Knowing as we do that preventive services can be confusing for physicians and our staff, just imagine what our patients are going through without informed assistance. By encouraging our staff to help patients and expanding our own understanding, we can help people receive the services they need to stay healthy.

My New Year's resolution is to advocate for significant payment reform that values the comprehensive care we provide and allows us to spend more time caring for our patients and less time worrying about coding and billing! Happy New Year.

Lynne Lillie, M.D., is a member of the AAFP Board of Directors.

Posted at 04:02PM Jan 18, 2017 by Lynne Lillie, M.D.

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