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Prev Med Svc + E/M Service - Same day

Sandra Posted Wed 09th of November, 2011 16:18:29 PM

Dear Forum: I apologize for the length of this request for opinions, but feel that what follows, is needed, breaking down the components in this specific clinical circumstance. ***I should tell you - I've spoken with CMS and our MAC, giving the query serious consideration, meeting more than once, incluing medical directors, other admin staff, and coders. Though I got some “nods” over the phone, leaning my way, it won’t go on record. Other of the many coding sources vary, as you know --Below is my quoted query, my argument, down to the p.s., regarding 3 chronic stable illnesses in the setting of a Prev Med Svc encounter. I appreciate the value of constructive debate, and would like opinions:
" *** Despite the limited scope of Prev Med Svc per CPT via the AMA -- 1) Isn't it a reasonable expectation that PFSH would be reviewed with the pt in Prev/Well visit, and to include pt’s experience with chronic illnesses, and therefore, does not represent “significant additional work”, (i.e., “here for annual; h/o HTN, DM-2, Hyperlipidemia - says compliant w/med and diet - home BP and BS have been wnl; has been in here in clinic as well; pt w/o complaints/concerns today; reviewed, in total, with pt, his FHx and SHx located in last Prev/Well visit 7/7/10 - pt denies changes”)?
2) Might some such tests as CBC, CMP, lipid profile, UA, EKG be performed in a Prev/Well encounter; some in the absence of aforementioned conditions; some, medically indicated – in the setting of existing chronic and historically stable conditions; some, performed, based risk factors (FHx = screening), and therefore, would not represent "significant additional work"?
3) Exam is normal, and does not require scheduled work-up, above that which is typical of a Prev/Well visit, or medically indicated, as described in, point #2,and therefore, does not represent “significant additional work”?
4) Isn't it a reasonable expectation to discuss diet, exercise, other lifestyle modifications, and risk interventions, in a Prev/Well visit, and therefore, does not represent “significant additional work”, in the presence of existing conditions for which they are indicated, when those conditions are/have well-managed and stable?
So I ask you then – what do you consider “significant”and “additional work”? I consider “significant”, “requiring additional work”, as a new or different abnormality/medical problem, a change or exacerbation of existing problem, abnormal exam, any of which, requiring scheduled work-up, based on clinical judgment, of course.
***I am pro-practice revenue, but first and foremost, pro-compliance. When I find that the physician/NPP down-coded, additional reimbursement is due. On the other hand, when I find that the services were up-coded, I see that a refund is processed.
***It is understood that good judgment must be applied, and only that which is medically necessary in order to diagnose and treat the pt, and/or to maintain or improve the pt’s health status, should be considered when determining the appropriate level of E/M service, no matter the reason for the encounter.
Your decisive answer is appreciated, as this subject/clinical circumstance has been debated for years.
Sandy Stevens, CPC
p.s. If you would like, I have examples of my audits, coding solutions, and rationale. Admittedly, not all, in this clinical circumstance were Prev-only, based other considerations, I'll spare you, unless queried.Thanks again."

Dear fellow coders - Thank you for opinions. I welcome friendly debate.

SuperCoder Answered Wed 09th of November, 2011 20:58:11 PM

Answering in a very brief manner to help analyze the 'specific issue' regarding "additional work-up.

Query 1: Agree with you.
Exception: when any of the existing or chronic condition is not stable even with medication. This can be considered a reason for visit or chief complaint and demands additional work-up.
Query 2: Agree with you in the context as you stated that with the existing chronic conditions routine clinical check-up, lab tests, or radiological exam to know if the present status is stable or exacerbating.
Exception: If result is exacerbating and warrants additional work-up towards evaluation of severity of the problem.
Query 3: Agreed.
Query 4: Agreed. Lifestyle, Diet, and Exercise-based Interventions are part of Prev.E/M based on age, sex, and other social factors.
To determine that whether it needed an addiional work-up during a preventive medicine services, there are some significant key feature to differentiate.
a. Prev./Well Visit is NOT problem-oriented and doesn't involve a chief complaint or present illness.
b. Comprehensive Exam performed as part of Prev.Med is Multi-System, but its extent is based on age and risk factors identified. A Single System-specific Exam is performed in Problem-oriented visit.

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