Billing Office Visits with Wellness and Preventative Visits
Introduction
Speaker: Betsy Nicoletti
Excited to discuss billing for office visits with a preventive medicine service.
No financial disclosures.
Learning Objectives:
Focus on recent changes and enduring issues surrounding billing for preventive services.
Discussion includes common practices that have remained constant over the years.
Case Scenarios in Preventive Medicine Billing
Common Scenario: Patient visits for preventive service but discusses acute/chronic issues.
Options for billing:
Bill for both preventive service and problem-oriented visit.
Perform both, bill only for the preventive service.
Schedule another appointment, risking patient will delay.
Recommended Approach: Perform both services and bill for both.
Document clearly to overcome objections in billing.
Example 1: Medicare Wellness Visit
Patient is a Medicare recipient attending an annual wellness visit.
May present with multiple chronic conditions (e.g., up to eight).
Comprehensive care includes checking blood pressure logs, managing anxiety, and providing preventive counseling.
Billing: Charge for both office visit and annual wellness visit.
Example 2: Frequent Visits with Stable Conditions
Patient with chronic renal disease and gout visiting frequently.
If seen for wellness visit after recent visit for a problem-oriented service, focus on risk factor reduction.
Billing: Charge only for the wellness visit due to the nature of the appointment.
Example 3: Child Wellness Visit
Parent brings child for well visit, and clinician notices increased use of a rescue inhaler.
Initial focus is on the well child visit, discussed preventive measures such as vaccines.
Billing: Charge for both the well child visit and problem-oriented visit due to the observed issue.
Definitions of Preventive Medicine Services
Preventive Medicine CPT Code Requirements:
An age and gender-appropriate history and physical exam.
Anticipatory guidance and risk factor reduction based on the patient’s demographics.
Medicare wellness visits involve extensive prescriptive measures requiring more data collection prior to the visit.
Emphasizes personalized prevention plans tailored to the patient's needs.
Personalization should account for any unique issues the patient has conveyed (e.g., falls).
American Medical Association Guidelines
Cited guidelines indicate when both services can be billed together:
Found conditions requiring additional history not presented by the patient.
E.g., lump found on breast exam or otitis in a child diagnosed during a preventative visit.
Emphasizes that comprehensive examination findings can provide justification for additional visits.
Instances for Billing Both Services per AMA
Patients with stable chronic conditions still require documentation of interaction.
Additional history must be present in HPI for billing to be compliant.
Emphasis on good documentation practices to substantiate services performed.
Coding Guidelines and Recommendations
Recommendations reflect common practices based on cumulative experience of billing professionals:
Without change or worsening conditions, billing guidelines do not restrict billing for stable chronic conditions.
Poll Question: Frequency of adding problem-oriented visits during preventive visits; recommendations emphasize good record-keeping.
Level of Service Determination
Level 3 Visits: Noting acute uncomplicated issues or one chronic stable condition
Approximately 30% of visits are classified as Level 3.
Level 4 Visits: Require addressing multiple chronic conditions or undiagnosed new problems with uncertain prognosis.
Commonly occur under similar circumstances as preventive services.
Important to document the reason behind the service level, especially in complex cases.
Examples of inappropriate billing practices include charging Level 2 for substantial problems without support, affecting overall audits.
Insurance Review and Cop relationships
Insight into patients' expectations for billing and possible objections.
Need for clear communication around what constitutes a copay and how it's applied to preventive visits versus problem-oriented visits.
Recommendations: Implement scheduling strategies to limit confusion regarding copays.
Documentation and Coding Practices
Importance of maintaining clear and separate documentation for multiple services to ensure audit compliance.
Coders may pressure physicians for simplified notes; however, each service must stand as independently justified.
Assurance needed from coding staff to reinforce that additional documentation for the problem-oriented service is permissible without tight restrictions.
Uncovering External and Internal Pushbacks
External coding objections primarily stem from insurance billing rules—need for compliance with specific insurance company guidelines.
Strategies for addressing coder feedback:
Educate coders on AMA and CPT guidelines to ensure compliance clarity.
Utilize supportive peer-reviewed articles as reference for pushback:
Emphasize the independence of visits as documented.
Possible barriers noted include requirements for two separate notes versus a single comprehensive note to cover all components.
Conclusion
Final Recommendations:
Encourage utilization of a unified template for services to streamline coding and enhance compliance checks.
Regular review of billing practices against CPT guidelines for accuracy.
Foster continuous education within practice settings to ensure all staff are informed of current coding standards and guidelines, particularly where they intersect with preventive care services.