Coding for Preventive Care, Smoking Cessation
Stantz, Renee, Medical Economics
Q: What am I doing wrong in coding below? Should I exclude 30SJ and 493.90 from 9920S and 99385?
99205 25 493.90, 786 2, 477.9, 30SJ
99385 25 493.90, 7862, 477.9, 30SJ
99407 25 305.1 - Insurance didn't pay ("Not separately reimbursable service")
94010 25 30S.1
94375 493.90 - Insurance didnt pay ("Not separately reimbursable service")
A: These are very good questions that include several areas of coding, which I will address separately.
Preventive and E/M coding (99205 and 99385): When billing a preventive and E/M code on the same date of service, the preventive code is billed as a new patient code (as you've done), and the E/M code is billed as an established patient code (99211-99215). The preventive visit code is billed without a modifier, and the E/M code is billed with the -25 modifier. Most payers wont pay for two new-patient codes for one date of service
If a provider's exam includes both preventive and medically based components, then the documentation for the E/M (medical) code cannot include elements that constitute the preventive medicine visit If a provider, for instance, would check the patient's vitals, heart, and lungs for a preventive exam, then those elements cannot also be included in the level for the E/M code. Without seeing the documentation for this visit I would say that it is very unlikely that the documentation would substantiate a full preventive exam and a 99215.
Modifier 25: As the description indicates, this modifier is for a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" and should be appended to E/M services only. Therefore, the 25 modifier would not be appropriate to append to 94375 or 94010.
94375 and 94010: According to National Correct Coding Initiative edits, 94375 (respiratory flow volume loop) is a component of 94010 (spirometry), so 94375 cannot be billed in addition to 94010.
Tobacco cessation codes: The following are some tips.
* Treat smoking cessation documentation as you would a surgical procedure during an E/M and document it separately. The documentation doesnt have to be in a completely separate note, but documenting in a separate part of the note helps distinguish the smoking cessation service from any other E/M services provided. …