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Don’t cheat yourself. That’s the health plan’s job.

Fam Pract Manag. 2006;13(4):14

One small symptom of the madness of today’s health care system is the bundling of preventive and problem-oriented evaluation and management (E/M) codes by health plans. This issue’s cover story by Cindy Hughes, CPC, discusses tactics for dealing with the problem, but there’s no really good solution. To get the reimbursement you’ve earned, you pretty much have to take it out on your patient, making him or her pay two co-pays and come in twice for what could be handled in one visit. And given that you’re out to serve your patient above all, chances are that you’ll tend to provide both services in one visit and take the reimbursement hit, maybe only billing for the preventive service. But wait; think twice before you do the health plan’s dirty work.

Why bother to bill for two services if you know you’ll only be paid for one, you ask? To start with, CPT tells you to. If you provide a significant, separately identifiable E/M service on the same day as a preventive service, you just attach modifier -25 to the problem-oriented code and bill for both. Period. As Hughes says in her article, “you’ll be following the CPT rules, which is what you want the health plan to do.” Submitting the double claim may seem like unnecessary work if you know the two services will be bundled and paid as one, but consider the implications of billing for just one of the services:

  • You’ll be misrepresenting the amount of work you do. If your practice measures productivity in terms of relative value units (RVUs), for instance, and you code for, say, a 99396 preventive visit when you’ve really provided both that service and a 99213, you’ll be giving yourself credit for 1.53 work RVUs when you’ve really earned 2.2.

  • You’ll be letting the payer off easily and hiding the problem.

  • If a miracle happens and the health plan later follows Aetna’s lead in deciding not to bundle such claims, and does so retrospectively, as Aetna did, you’ll have the information you need to resubmit your claims, and you might actually get paid!

No, there’s not a lot of percentage in it for you, but there’s some. And even knowing that the system is going to stiff you no matter what you do, you still have the faintly ridiculous but nevertheless bracing moral satisfaction of knowing that you’re giving your patient the best care and service you can and you’re doing the right thing yourself.

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Copyright © 2006 by the American Academy of Family Physicians.

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