Author Topic: Preventative billing issues  (Read 1348 times)


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Preventative billing issues
« on: December 08, 2014, 01:43:29 PM »
Does anyone have any resources other than aap website that would give a good description of what should be done during a well child exam?
1) Doctor trying to bill for E/M on well exams. Generally he is only noting that there is another condition but nothing is significant to allow separate E/M for it.
2) Doctors are trying to bill 96110 on every well child exam. He says this is done but there is no questionaire filled out, no testing documenation or report is done. He's billing it on newborns/infants too.
I need to be able to show what is included in well exam and why separate visit isn't warranted in most cases. Most importantly why 96110 isn't appropriate for newborns/infants.
Any help is appreciated! Thanks


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Re: Preventative billing issues
« Reply #1 on: December 08, 2014, 10:01:20 PM »
For #1, the provider needs to understand that if there is going to be an EM billed on the same day as a well exam, there has to be a separate note for that EM, that stands alone from the well exam, and has all the components needed to get to the level chosen. There are numerous articles, etc, on the internet that address this. But what it comes down to is basic EM documentation, which is explained quite thoroughly at the CMS website, here:

If he has done the work to bill an additional EM, he can bill it. If not, he can't.

I see a lot of questions about this very situation on various forums...the child comes in for a well exam, has something else going on, and because the provider makes mention of it or the parent/child mentions it, they want to bill a separate EM. Nope. Either they do everything needed for that EM right then, and bill it, or they don't, and they have the patient come back for another appointment, and bill it then. In many cases, it is so minor, that they can handle it right then, nothing extra is billed, and that is that.

For #2, I Googled the CPT code 96110, and got a lot of hits explaining when/how to bill it, including one health care fraud alert about the over-billing of the code. One hit, from a Medicaid site, said that for the 0-3 year range, it should be billed at 9 mos, 18 mos, and 24 mos. Based on the code description, how it could be billed on a newborn is beyond me...just because it says 0-3 years, doesn't mean it gets billed on newborns/infants. And with no clear documentation being provided as to how the code is being billed, well, that falls under "if it wasn't documented, it wasn't done".