Author Topic: Preventive exam on a comercial insurance  (Read 1915 times)


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Preventive exam on a comercial insurance
« on: November 07, 2014, 12:48:12 PM »
I perform preventive exams on my patients once a year ( they call it a physical ), but once in a while they have other issues that need to be address, like a cold, or abdominal pain, or headaches. If I address these and treat these, can I bill for that also?


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Re: Preventive exam on a comercial insurance
« Reply #1 on: November 07, 2014, 01:13:20 PM »
In my experience most insurers will cover an office visit charge for a problem focus that arises during a routine preventive exam. The documentation must support the separate E/M service and it is highly unlikely you would be able to do enough to justify 99215, so a lower level visit code would be most appropriate for the majority of situations. Medicare does cover this as well and most of the commercial insurers we work with go by Medicare's rules for this. From the CMS Claims Processing Manual, Ch. 12:

"H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV
When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).
NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service."

One thing to remember though, is that many patients, especially women and children, are expecting their annual physical exam to be covered with no out of pocket or deductible costs per the new ACA requirements, so if a problem focus does come up it would be courteous of the provider to let the patient know that it will not be covered as part of the no-cost exam. I've had a few confused friends/family members bring me EOB's because they don't understand why they ended up having to pay for their supposedly "free" exam. They wouldn't have brought up non-urgent/minor concerns if they had known.
« Last Edit: November 07, 2014, 01:17:48 PM by shanbull »