billing 2 E&M visits on New Patient same day

michele.fecho@readinghealth.org · August 2016

I know this was addressed before but where can I find something to support this:

New patient comes for annual visit & problem addressed. We thought you could only bill new patient for one (preventive) & the other E&M code has to be established. Correct?

Thanks

KarenHurley · August 2016

It depends on the plan's rules.

Karen A. Hurley, BS, CMM, CPC, CNA
President, HPMSI
PO Box 409
Parrish, FL 34219
Tel: (941) 776-4822
Fax: (240) 368-0059
Web: www.hpmsi.com

mbb@preventive-med.net · August 2016

Due to the duplication of documentation requirements for 2 new pt codes (3 out of 3 areas.. hx, exam, mdm) it is generally easier to meet new pt level on preventive exam and then established pt on e/m since the established only requires 2/3 elements.

Dawn Breithaupt CPC
Preventive Medicine Associates

kristenbeury · August 2016

Michele,

Could you supply a little more information on the patient payor type and give a few scenarios? Would love to further assist as we specialize in these types of program implementations throughout the US.

Thank you!

Kristen M. Beury
President/CEO
Medical Resource Association, Inc.
Telephone: 1-888-279-0232 x102
Fax: 1-866-804-6331
http://www.facebook.com/medmanagement
Skype : kristenmrasrq
Web Site: www.mrasrq.com

kristenbeury · August 2016

I concur Karen! Yes.

Kristen M. Beury
President/CEO
Medical Resource Association, Inc.
Telephone: 1-888-279-0232 x102
Fax: 1-866-804-6331
http://www.facebook.com/medmanagement
Skype : kristenmrasrq
Web Site: www.mrasrq.com

seth.canterbury@jax.ufl.edu · August 2016

Sorry, but incorrect The patient is considered "new" for the entirety of their first encounter to the office. If multiple E/M codes are necessary to describe the services rendered during that one encounter, “new” codes are used for all. The patient doesn’t flip from new to established mid-encounter. “Established” E/M codes would only be used once the patient actually leaves the office and comes back for a new encounter.

From the October 2006 CPT Assistant:

...if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate).

Seth Canterbury, CPC, CPC-I
Clinical Data Quality Education Department
University of Florida Jacksonville Physicians, Inc.
653 West Eighth Street
Tower I, Suite 606
Jacksonville, FL 32209

michele.fecho@readinghealth.org · August 2016

Pt had Highmark. She came in for her annual GYN exam & MD counseled her for 30 minutes (totally unrelated to her annual visit regarding menorrhagia & surgery.) He wanted to bill new preventive code & 99203. From your posts, I am hearing this is ok. I guess it would be difficult to get a 99203 based on history, exam & MDM since most of the exam would be considered part of her annual but using time, it works, correct?

KarenHurley · August 2016

But, as we know – the health plans overwrite the copyrighted descriptors for CPT. Even when using the citation for the appeal, it can still be denied.

A large Blue Cross Blue Shield payor on the East Coast does not conform to this CPT Assistant notation.

It will still go back to payor rules and what they will consider as being appropriate under the physician’s agreement with the plan.

Karen A. Hurley, BS, CMM, CPC, CNA

President, HPMSI

PO Box 409

Parrish, FL 34219

Tel: (941) 776-4822

Fax: (240) 368-0059

Web: www.hpmsi.com

seth.canterbury@jax.ufl.edu · August 2016

True, but the point is that a citation explaining the correct way to code this does exist. This is not an issue for which no authoritative guidance exists and individual payer rules are all that matter. Can payers choose to ignore CPT and do their own thing? Sure, just as they can in any other coding situation, but that fact doesn’t diminish the importance of first establishing the correct way to code something when authoritative guidance identifies such a way.

My personal belief is that we should always bill it the correct way (per CPT) first (even if we’ve heard that the payer prefers coding method X), and if a denial is received from a certain payer we will have evidence that they do not pay for the legitimate servicer using the correct coding method. My preferred next step is to attempt to convince them to accept the correct coding method. Most payers do not intentionally create coding policy contrary to CPT instruction, but do so out of ignorance, and some will alter their processing methodology to harmonize with CPT and other payers. If this does not work and we are forced to bill in an incorrect (per CPT) manner to receive payment, and the payer’s staffing/processing software/policies change later, we are at least partially protected from inquiries by the payer as to why we billed it “wrong” for time period X, having the denial(s) in hand from where we attempted to do this.

Seth

KarenHurley · August 2016

I 100% agree – it has been my company’ mission since 1996, have won some great appeals.

I always have at least one mission on the table – right now it’s Medicaid MCO’s that are secondary to a primary insurance (usually an Obamacare policy with a high deductible), who do not recognize the global OB care codes. Primary pays on the global codes – but Medicaid MCO denies as ‘not covered’ on the secondary claim. Some of these patients have deductibles as large as the fee.

Maryland Medicaid now has to come up with a plan that can process the claim without the provider ‘changing the code’ to have it go through their system.

Never a dull moment in 20 years.

Karen A. Hurley, BS, CMM, CPC, CNA

President, HPMSI

PO Box 409

Parrish, FL 34219

Tel: (941) 776-4822

Fax: (240) 368-0059

Web: www.hpmsi.com

Cathy · August 2016

Karen, our local Medicaid (Oklahoma) is switching to the individual billing of OB visits effective 9/1/16, and one of our major concerns is how we are going to deal with the secondary Medicaid claims where they expect us to go back and "fix" the charges to they way Medicaid wants them.

Cathy Satkus, CPC
Harvard Family Physicians
918-743-8200

mlewis@scrogginsgrear.com · August 2016

We have had that kind of billing for Medicaid as long as I can remember- each visit individually.

Maxine

Maxine Lewis, CMM, CPC, CPC-I, CPMA, CCS-P

Main: 513-771-7070
Direct: 513-672-4363

Fax: 513-326-7640

200 Northland Blvd

Cincinnati, OH 45246

mlewis@scrogginsgrear.com

www.scrogginsgrear.com

KarenHurley · August 2016

Medicaid is partially federally funded and there has to be some rationale with this craziness. I get it if they want it billed differently on a primary claim, but not on the secondary – that’s inappropriate and isn’t correct for accounting reasons to reconstruct a claim.

I received a response from Amerigroup (a DC/MD/VA Medicaid MCO) today – they indicated the secondary claim I sent to them was denied incorrectly and they will have it reprocessed. Since it was a paper claim with an attachment, it could be a data entry error. They could see the claim and the attachment and all was good, it processed incorrectly.

We have 2 other Medicaid MCO’s we are par with, so I am watching those claims, too.

With fat deductibles on the primary – the state Medicaid secondary is going to owe more than they thought………..probably something state legislators didn’t think about.

Karen A. Hurley, BS, CMM, CPC, CNA

President, HPMSI

PO Box 409

Parrish, FL 34219

Tel: (941) 776-4822

Fax: (240) 368-0059

Web: www.hpmsi.com

billing 2 E&M visits on New Patient same day

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