One of the more complicated coding and reimbursement issues of recent years has been the attempt by providers, payers, and patients to agree on how to collect reimbursement for preventive services provided in conjunction with medical management services.
The CPT manual clearly separates these two types of E&M services. Preventive service codes cover routine or periodic health maintenance, while in-office or outpatient service codes cover the management of acute or chronic medical problems. From a coding perspective, these service categories are further differentiated from one another by diagnosis coding. Preventive service codes are accompanied by screening type v-codes, while medical management service codes are identified by a specific disease, condition, or signs and symptoms.
Providers use a number of terms to describe the preventive services they offer. For any given office visit, physicians may record that a patient presented for an annual exam, CPE, CPX, health maintenance, routine exam, follow-up, or CDF (chronic disease follow-up), among others. Rarely does a provider clearly state that a patient presented for “health maintenance and the management of problem one, problem two, etc.”
Payers also seem to have difficulty clarifying to physicians how they expect them to deliver certain covered services. Most HMO, PPO, or managed-care entities cover some type of annual preventive service. Almost all insurance plans cover office visits for the medical management of specific problems. But what happens when physicians provide both services in the same visit?
The answer can very much depend on specific payers. Different payers handle this scenario different ways. Historically, many commercial or managed-care payers have not covered both services when they are performed during the same visit. Usually, one of them is denied.
This may seem a bit odd when both are typically listed in payer contracts as covered services. However, during claims processing, one of the coded services is commonly treated as a “limited-covered service” — that is, it’s not covered when performed with the other service. This reality is not always clearly indicated in any given payer’s provider manual or contract. In other cases, payers may clearly state that only one E&M service type is reimbursable on a given day.
So if confusion reigns among both providers and payers in such cases, where does that leave the patient?
In many ways, patients unknowingly perpetuate this problem. Most patients don’t give much thought to the type of professional medical services they request; the nuances of service types are the realm of payers and providers. CPT and ICD-9 code variations and combinations are the mysterious mechanisms of exchange between providers and payers. Patients are largely unaware of the specifics of these transactions.
When a patient arrives for an appointment with his physician — whether for an annual exam or to talk about a specific problem — he usually feels quite free to discuss or question his physician about whatever healthcare issues are on his mind, be they preventive or related to a specific problem. Patients don’t make that distinction.
To implement policies within your practice that will help you deliver appropriate healthcare under the reimbursement rules that currently prevail, the patient needs to be included in the equation.
Having patients complete forms that indicate the purpose of their visit clarifies their expectations for specific encounters. It’s a starting point for the practice to begin managing the patient visit and to determine how to handle the requested services properly.
Managing patient plans
Next, rather than simply copying the patient’s insurance card and ID numbers for filing a claim, find out precisely what plan the patient has, what it covers, and any potential exclusions or limitations before you provide the requested services.
Yes, this is a lot to ask, but most practices deal with a finite number of payers and plans, and although they do change, you can usually quickly learn the type of coverage the majority of your patients carry. Once you have this information, you can conduct an intelligent discussion with your patients about their options.