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  • #46
    Originally posted by AR View Post

    I've never really understood bolded. You are supposed to do a physical exam, but if you find a funny looking mole on your exam, then there is a separate charge?
    Yes, if during the exam I find a suspicious mole then I can bill a separate visit in addition to your free physical visit….that separate visit would either go toward your deductible or would trigger your copay.

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    • #47
      Originally posted by Savedfpdoc View Post

      Yes, if during the exam I find a suspicious mole then I can bill a separate visit in addition to your free physical visit….that separate visit would either go toward your deductible or would trigger your copay.
      In that case, could you answer the question I asked earlier

      I still don't understand how you justify billing the second E&M code in this case. You do an exam and you see a suspicious skin lesion. Here are some things you could do

      1. You could do a biopsy of it (in which case that should be billed for separately, and the biopsy code includes time spent evaluating the lesion)
      2. You could refer the patient to another specialist for a biopsy (you said this wouldn't be enough to justify the additional E&M code)

      So what justification do you use? I'm not saying there isn't one, I'm just curious about what you would use in this specific case.

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      • #48
        Originally posted by Lordosis View Post

        The skin lesion is a bad example.
        That was kind of my point. A skin lesion was brought up by someone else as something one would bill for during an annual exam.

        However, your explanation of how you would handle it in that scenario seems completely reasonable and makes sense to me.

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        • #49
          Re separate billing: 9939X -25 modifier.
          9921X (for their uncontrolled DM / new back pain/ whatever)
          As I mentioned before, our coding/compliance people -- who are ludicrously conservative - have said that an E&M is not paid for at a wellness series 9939X. Is there a chance they are lying? Or do payors vary that much state to state? Additionally, for those who do the 9921X modifier, do you have some who pay and some who don't?

          Right now, it's only my medicare wellness patients who get 9921x-25 + AWV G code. Even then our compliance person gets her panties in a wad without very clear documentation. And luckily I know how to play that game and teach others to play that game too.

          (Off-topic: if you are primary care and bill 99215's, I would be interested in vignettes or even anonymized snippets of a note. Same coder is pretty ridiculous about 99215's. Management sent out "initiation of methotrexate" as the kind of visit that warrants a 99215 - oh so primary care focused - and if there isn't clear threat to life or limb pushes back on 99215's. Whereas I think an uncontrolled hypertensive uncontrolled diabetic multiple labs and review of chart and multiple med changes probably does in fact qualify. Right now I get a lot of 99214.99999's).

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          • #50
            Now only if I could bill a separate E&M code for counseling for obesity during a physical I would double my productivity!

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            • #51
              Originally posted by gap55u View Post
              Re separate billing: 9939X -25 modifier.
              9921X (for their uncontrolled DM / new back pain/ whatever)
              As I mentioned before, our coding/compliance people -- who are ludicrously conservative - have said that an E&M is not paid for at a wellness series 9939X. Is there a chance they are lying? Or do payors vary that much state to state? Additionally, for those who do the 9921X modifier, do you have some who pay and some who don't?

              Right now, it's only my medicare wellness patients who get 9921x-25 + AWV G code. Even then our compliance person gets her panties in a wad without very clear documentation. And luckily I know how to play that game and teach others to play that game too.

              (Off-topic: if you are primary care and bill 99215's, I would be interested in vignettes or even anonymized snippets of a note. Same coder is pretty ridiculous about 99215's. Management sent out "initiation of methotrexate" as the kind of visit that warrants a 99215 - oh so primary care focused - and if there isn't clear threat to life or limb pushes back on 99215's. Whereas I think an uncontrolled hypertensive uncontrolled diabetic multiple labs and review of chart and multiple med changes probably does in fact qualify. Right now I get a lot of 99214.99999's).
              I bill for physicals and office visits and don't get any pushback. Nor any issues with the AWV + office visit code. I had more issues with the old documentation rules, but that is less of an issue now.

              I definitely bill 99215s, more frequently than before, but still not often. With the new coding rules, time alone will sometimes help me achieve that (no longer just time spent in the room). The time is typically the component that gets me the charge, but any patient being sent to the hospital or concern for something more serious (DVT/PE, for example), I can get the charge to go through.

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              • #52
                Originally posted by Kennyt7 View Post
                Shouldn't there be some physical examination of mouth, ears, lungs, prostste
                and an ekg every yr
                no more chest X-rays???
                Screening chest xrays are not reimbursable. We also don't get paid for reading "pre-op" chest xrays. We also don't get paid for anything if our report history is "Rule out....", there has to be an appropriate clinical symptom.

                While I'm on this totally unrelated rant....it drives me nuts how the insurance carriers will keep changing what verbiage has to be in our reports before we can get paid. Its a game, they keep changing it so a percentage of our billing just doesn't get reimbursed.

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                • #53
                  So do you PCPs out there like the patients who just come for their annual physical and don’t have any complaints/meds/etc or do you feel it is a waste of time? I go for my recommended screening and keep an annual visit with my PCP because I feel like it’s good to have a PCP in case something comes up…but maybe I’m wasting her time. On the other hand, whenever I see patients with random badness I always like to know what their original symptoms were because I feel like I will have a tendency to downplay anything until it becomes too late.

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                  • #54
                    Docs and nurses are worst patients, remember? We tend to ignore until WAY too late. So yes, routine annual visits are nice and the rare 'all's good' see you next year is a welcomed visit. -- fast, efficient --- just like a 15minute oil change should be to keep things rolling and making sure the little squeaks are just that.

                    Sadly these routine checks with nothing to do is a significant minority of my work week.

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                    • #55
                      Originally posted by StarTrekDoc View Post
                      Docs and nurses are worst patients, remember? We tend to ignore until WAY too late. So yes, routine annual visits are nice and the rare 'all's good' see you next year is a welcomed visit. -- fast, efficient --- just like a 15minute oil change should be to keep things rolling and making sure the little squeaks are just that.

                      Sadly these routine checks with nothing to do is a significant minority of my work week.
                      Sounds about right. Last Friday I somehow had a bunch of 6mo followup patients, everyone was stable, rolling along. Made for an easy day for sure

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                      • #56
                        Originally posted by Anne View Post
                        So do you PCPs out there like the patients who just come for their annual physical and don’t have any complaints/meds/etc or do you feel it is a waste of time? I go for my recommended screening and keep an annual visit with my PCP because I feel like it’s good to have a PCP in case something comes up…but maybe I’m wasting her time. On the other hand, whenever I see patients with random badness I always like to know what their original symptoms were because I feel like I will have a tendency to downplay anything until it becomes too late.
                        I think the value depends on the age. There is definitely plenty of counseling I do based on age (probably most counseling in my adolescent age-group). But then there are cancer screening/counseling as patients get older. Vaccinations can be kept up to date. It's also a good time to review medical history, as this sometimes changes screening recommendations as well.

                        Don't get me wrong, some physicals are "easy". However, they are reimbursed well, and there is a lot that can be gathered during those visits. I'd rather I get MORE patients to come in for their physicals, as some will only come in when they have something wrong or need meds refilled and try to ignore some of the screenings.

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                        • #57
                          So do you PCPs out there like the patients who just come for their annual physical and don’t have any complaints/meds/etc or do you feel it is a waste of time?

                          Probably some of the time , just like changing your oil every 5000 miles , when you use synthetic oil.

                          Most insurance will cover annual visits / preventative at 100% with no co-insurance. So some one must think it is beneficial in either preventing disease or unnecessary use of health care dollars. I think the latter.

                          Informed patients , which I assume you are, eat well , dont smoke , dont drink too much only smoke weed occasionally are less likely , at least in my opinion to benefit Others who are less likely to be informed either from lack of education , other resources ,or are miss informed from Dr. Google probably derive more of a benefit.

                          Today I had a 55 year old , who had palpitations last Nov, thought she was stressed , otherwise felt well , here for her annual check up, had a HR 132 in afib. So this routine stressed otherwise asymptomatic lady , turns into a whole separate issue real quickly.

                          I can't tell you how many skin cancers I pick up , just by lifting up someone's shirt and looking at their back.

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                          • #58
                            Originally posted by Anne View Post
                            So do you PCPs out there like the patients who just come for their annual physical and don’t have any complaints/meds/etc or do you feel it is a waste of time? I go for my recommended screening and keep an annual visit with my PCP because I feel like it’s good to have a PCP in case something comes up…but maybe I’m wasting her time. On the other hand, whenever I see patients with random badness I always like to know what their original symptoms were because I feel like I will have a tendency to downplay anything until it becomes too late.
                            It is a good chance to get to know your healthy patients. Those people are rare though. Usually they come in because of some stick or carrot from their employer/insurance.

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                            • #59
                              Originally posted by Anne View Post
                              On the other hand, whenever I see patients with random badness I always like to know what their original symptoms were because I feel like I will have a tendency to downplay anything until it becomes too late.
                              My wife and I have resigned to the fact that we’re going to die of something stupid and easily preventable.

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                              • #60
                                Originally posted by AR View Post

                                In that case, could you answer the question I asked earlier
                                The justification is easy…the suspicious mole would require a separate discussion with the patient and meets the criteria for using modifier 25 “a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”

                                Keep in mind just bc I can bill it doesn’t mean I always do. I would do as someone else here said..just put in a referral to derm without billing a separate visit. But if it was a back pain or knee pain complaint then I’d likely bill it separately

                                i was commenting to highlight the fact that right or wrong, we physicians (esp primary care) are expected to do a lot more free stuff than specialists. And patients have no shame in complaining about an extra charge.
                                try asking the surgeon to bill for only The colostomy placement and not the take down, or try asking the they gyno to bill only for the c section and not the tubal ligation

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