Dealing with one of the most dreaded billing dilemmas.
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.
Reimbursement or coverage problems typically do not arise when a visit stays within an E&M service type. If a patient presents for problem management, new or chronic, stable or exacerbated, code types 99201 to 99215 will generally be reimbursed as long as other issues involving deductibles, copays, pre-existing conditions, or medical necessity don’t trigger a claim denial.
Likewise, when a visit is wholly preventive in nature, and a patient’s coverage allows it, reimbursement usually isn’t an issue. It’s the blending of these two types of services that can cause problems. Called “combination coding,” “split-visits,” or sometimes even “double coding,” all terms indicate that two types of services have been provided.
Visits that call for “combination coding” are very common. What patient wouldn’t want to make the most of a visit by addressing new problems during regular preventive health management appointments? Physicians are familiar with the “laundry list” of problems patients often take to them, paving the way to the land of mixed services and uncertain reimbursement.
The Medicare model
For many years now, Medicare has had a mechanism to deal with the “split-visit” phenomenon.
Traditional fee-for-service Medicare Part B does not pay for global preventive services - those requiring 99387 and 99397 codes. If a physician provides such services and nothing else to a Medicare patient, they are not covered and are the responsibility of the patient. When physicians perform these procedures in conjunction with “a separate and significant E&M service,” a payment reduction formula shields the patient from the full charge of the noncovered service. Medicare will pay for a separate E&M, but the patient pays for the preventive service.
Given that most Medicare patients have a chronic condition that requires regular management and the reality that some older patients typically “save” a problem or concern for their annual visit, you can conclude that stand-alone preventive service visits for the majority of the Medicare population don’t often occur. Although this is the case, for years sympathetic providers have virtually given away preventive services and coded for only episodic or medical management E&M services to avoid inflicting financial insult on patients typically perceived as those least likely to be able to afford medical care.
But payers do address this situation. Medicare has in fact given us a pretty good model to follow for billing for two service types. Although CMS doesn’t cover preventive services outright, Medicare’s overall formula pays for their portion of medical management service and requires the patient to pay a reduced amount for the noncovered preventive service.
Rather than the “one or the other” approach that most managed care companies have adopted regarding such claims, some portion of each service is paid, one of them at nearly 100 percent of the rate. This is reasonable.
Movement on the managed-care front
However, there are certain managed care and indemnity plans that have always paid for both preventive and specific care services when they are performed during the same visit - if such services are properly coded and documented. These may be higher-end plans, but they do exist.
In recent months, there has been significant movement among managed-care plans to recognize that physicians who provide two services in one visit are in fact achieving some economy of scale when a patient’s problems require one visit rather than two. Perhaps some payers are moving toward covering both services within one visit simply because the overhead cost of appeals related to denying so many combination services can be substantial.
The CPT manual has long directed that when these two types of services are provided in the same session, they should be coded as such. Medicare echoes this. And at long last, commercial insurers also appear to be moving in this direction.
In several states, Blue Cross Blue Shield, Anthem, and other payers are covering both codes. It’s rumored that one of the largest commercial payers is also making policy changes in this direction. And recent indications are that both services will be paid at contract rates rather than discounted as in the Medicare model.
If this trend really takes hold, providers can confidently code for their actual services and payers can concentrate on real wellness initiatives and outcomes and rather than spending so much time managing denials and delivery patterns. Perhaps down the road the relative value weights for the combined services will be reflected in combined payments - maybe at a rate somewhat less than 100 percent of what both services would bring in separately - but much more reflective of the true resources physicians expend during combination visits. That would constitute real savings to the overall system.
Bill Dacey is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for over 18 years. He can be reached at firstname.lastname@example.org or via email@example.com.
This article originally appeared in the September 2006 issue of Physicians Practice.