By Sharon Davies, RHIA, CCS-P
Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the potential “extras” in mind.
When a patient presents for a complete physical exam (CPE)—also known as a preventive medicine service—just what is included? Per the 2016 CPT guidelines published by the American Medical Association, the services involved in this visit include “age and gender appropriate history, examination counseling/anticipatory guidance/risk factors reduction interventions and the ordering of labs or diagnostic procedures.” Whew, that’s a few things to remember.
Age- and gender-appropriate history and exam are the significant elements to consider for a meaningful CPE visit. Pertinent points of discussion and examination that are relevant to a 12-year-old male patient will differ when the patient is a 55-year-old woman. Counseling a patient to wear a helmet when cruising on their hoverboard, for example, may be less likely to apply to the 55-year-old. And examining the range of motion for arthritic knees may not be medically necessary for a 12-year-old.
Currently, providers have the ability to document what they feel is reasonable in a preventive medicine service. There are no specific hoops to jump through for each level. The provider must initially select if the patient is either new or established, then determine the age of the patient. Once these steps are completed, the practitioner is ready to begin.
So what about all those “extras” that patients often save up to include in their annual physical exam visit? When a patient presents for a yearly exam, can a provider charge for completing additional services during that visit related to that extra laundry list of ailments and still be compliant? According to the CPT guidelines, “if the problem or abnormality is significant enough to require additional work to perform the key components,” then it is acceptable to do so.
This is a clinical judgment call from the provider. They need to consider if the key components of history, exam, and medical decision making were documented and that the problem was medically significant. Can an outside auditor clearly carve out the “extra” elements that fall outside the norm for that age and gender patient? Discretion on the part of the provider should also be considered.
Questions to ask include:
- Was an extensive/thorough exam on a particular organ system performed that was outside the norm?
- Were diagnostic tests ordered outside the typical requirements for that patient?
- Were new medications and treatments initiated?
Answers in the affirmative to the above questions are all indicators that the abnormality is separately identifiable.
Modifier 25, which depicts a significant, separately identifiable E/M service, is appended to the E/M level. Linking this extra service to a diagnosis code demonstrates the medical necessity for requesting payment for two services on the same day. Check with your local carrier as this may differ amongst intermediaries.
An example for this situation could be a patient who presents for a check-up with a freshly sprained ankle. They were coming to see the provider anyway, as they had a previously scheduled appointment. After a brief history and examination the provider advises them to ice the ankle. This would not be considered “significant.” However, if the patient had seriously hurt their ankle, couldn’t bear weight, had diabetes, and needed prescription pain relief as well as an MRI, then that would be an additional work-up. In that case, the provider has earned an E/M level in addition to the routine complete physical exam that is typically performed.
Physicians and coding professionals should be cognizant of the fact that this physician now provided two services and generated two charges. A physical exam may be without a co-pay while an office visit will most likely generate a co-pay. Another consideration is that some payors don’t cover a preventive medicine visit. Providers must bill for the services rendered but it would behoove practices to instruct patients to verify their coverage when the initial appointment is made for a routine physical.
Get paid for the services that you perform and keep your patients happy, well cared for, and informed. As always, documentation is key—“Think in Ink.”
More Coding and Reimbursement Content Online
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American Medical Association. 2016 AMA CPT Professional Edition. Chicago, IL: AMA, 2016.
Sharon Davies (Sharon.Davies@rochesterregional.org) is senior compliance coordinator at Rochester Regional Health.
"Do You Want Fries With That? Decoding All the 'Extras' in Physician Visits"
Journal of AHIMA