Primary care providers’ main goal is the wellness and health of the patient. Preventive care is known to be at the top hierarchy of the primary care provider. Everyday Annual Physical Exams are scheduled to promote wellness and prevent diseases. However, in many occasions the patient presents with not only the need of a preventive service, but also with a Problem-Oriented condition needing the provider’s management. For these instances, one must give special attention in documenting and coding these visits to maximize compliance and reimbursement.
Governmental and commercial payers have created edits in their systems to scrub claims before adjudication and issue of payment. This scrubbing process carefully reviews and inspects claims looking for, among others edits, codes that can be grouped together. This grouping of codes has been given the name of Bundling, and its target has been set to minimize provider reimbursement whenever a claim is lacking the appropriate mechanism of UnBundling. Nonetheless, by using appropriate documentation guidelines and modifiers to untangle the net (Bundle), you can maximize your reimbursement and increase your profitability.
CPT and CMS Guidelines
One must begin by noting that according to the CPT (Current Procedure Terminology) guidelines the general components of a Preventive Service are:
- A Comprehensive History and Physical Examination
- Anticipatory guidance, Risk factor reduction interventions or counseling
- The ordering of appropriate laboratory or diagnostic procedure
- Management of “Insignificant Problems”
Even more, it is important to understand that the Comprehensive History and Physical Examination elements of a Preventive Medicine Service are NOT the same as those listed for a Problem Oriented Evaluation and Management service on the CPT guidelines. Furthermore, neither the 1995 nor the 1997 Evaluation and Management Services Guideline published by the Centers for Medicare and Medicaid Services (CMS) describe the requisites for preventive services.
UnBundle The Bundle – Get the Cash
The key then is on the Chief Complaint, The History of Present Illness and the Medical Decision Making. If a Significant Identifiable Problem (SIP) is addressed during the Preventive Medicine Service visit the documentation of this significant problem must be recorded following the CPT guidelines and either the 1995 or 1997 Evaluation or Management Documentation Guidelines. A SIP might either be a new problem such as chest pain, sore throat or a headache, or a chronic condition such as high blood pressure, asthma exacerbation that had been under controlled and it is now showing worse.
These SIPs mentioned above are evidently significant enough for the provider to include further work. The elements for a Problem-Oriented Evaluation and Management (CPT codes 99201 – 99205 or 99211 – 99215) are present. One can clearly identify a Chief Complaint, History of Present Illness and the need for Medical Decision Making. Lastly, the additional service needs to be identified on the claim to indicate the separate service and bypass the bundling process. After a Problem-Oriented E&M has been chosen a Modifier is used to identify the additional information. The CPT book guides to use modifier 25 to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. It is important to notice that modifier 25 must be added to the Problem-Oriented code in the claim.
As a primary care provider you maximize and efficiently treat patients to either control, manage or eradicate their ailments. On the other hand, you must also maximize your documentation, coding and billing to improve your profitability and financial health of your practice. By identifying separate services and following established guidelines you can promote the financial wellness and health of your practice.