“My insurance company told me you coded this wrong. Can you change the code so they’ll pay it?”
These aren’t words a physician or billing staff member wants to hear from a patient. Often the issue is about whether a service you provided was preventive or problem-oriented. The distinction matters to patients because Medicare and private insurers almost always pay in full for correctly coded preventive medicine services but often require a copay (or full payment from patients with high-deductible plans) for services to treat an acute or chronic illness. Be sure that preventive visits are coded as such.
Another mistake that has payment implications for you and your patient is choosing the wrong preventive medicine code. CPT defines a preventive medicine service (99381 - 99397) as an age- and gender-appropriate comprehensive history and physical exam that includes anticipatory guidance and risk factor reduction. These codes are defined by the patient’s age and whether he or she is new or established. Screening tests and the provision and administration of vaccines can be billed separately. The comprehensive history and physical exam are not synonymous with the comprehensive history and physical described in the evaluation and management documentation guidelines. Rather, the extent of the history and exam is dependent on the age and gender of the patient.
Although private payers reimburse for these services, traditional Medicare does not. Instead, Medicare developed the “Welcome to Medicare Physical" and annual wellness visits (HCPCS codes G0402, G0438, and G0439). According to Medicare, the goals of these visits are health promotion and disease prevention and detection.
Selecting the appropriate code will hopefully facilitate payment for preventive services and reduce some of the unpleasant questions.
— Betsy Nicoletti, a Massachusetts-based coding and billing consultant
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights," featuring practical, peer-reviewed advice for improving practice, enhancing the patient experience, and developing a rewarding career.