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While the Centers for Medicare and Medicaid Services (CMS) is expanding the range of medical services Medicare will pay for, many other types of routine related services remain uncovered. In cases such as a routine physical examination for a senior citizen, for instance, you will need to get Medicare patients to sign an Advance Beneficiary Notice that permits you to bill them, because Medicare does not cover this service.
However, in situations where a physician finds a patient has significant medical problems that require further investigation during an otherwise routine health exam, most practices either use a preventive code or an evaluation and management (E/M) code when billing the claim.
However, in such circumstances it is often appropriate to bill both a preventive code and an E/M code, which can have a major impact on the ultimate reimbursement.
Specifically, American Medical Association guidelines say it is acceptable to use codes from both categories when "the problem/abnormality is significant enough to require additional work to perform the key components of a problem- oriented E/M service."
In this situation, use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to append the code for the problem-oriented E/M service. In turn, Medicare should reimburse the problem-oriented code (99213).
Case study: A 72-year-old Medicare patient comes in for his routine annual physical. He has no complaints, and there is nothing on his chart since his last physical. During the examination, the doctor notes pallor and decides to perform a complete blood count, which reveals anemia. Additional clinical work is done to help find the cause of the anemia. Responding to questions from the doctor, the patient notes that he has been feeling a little off lately, but "has not really thought about it."
The documentation that has been gathered shows there are enough key components for physical exam and medical decision-making to justify a level 3 problem-oriented, established patient, E/M service.
In this case, the practice should bill for both a code 99397 (preventive medicine service, established patient, 65 years and older) and 99213-25 (level 3 office or other outpatient established patient visit, significant separately identifiable E/M service).
Tip: It is vital that the problem or condition be linked to the problem-oriented E/M under this coding combination. As such, two diagnoses should be placed on the claim. Code 99213 will not be considered significant or separately identifiable enough without a condition warranting use of the code.