Yearly physical

[gap55u]

My billing/revenue coders were seemingly shocked, but BCBS paid for a physical exam 99395 + 99214. We'll see how much that a) boosts my wrvu and b) simultaneously tanks my patient satisfaction now that patients don't get a free visit for their wellness plus 7 unrelated questions they've saved up for 4 months.

To the question at hand: I follow USPSTF for screenings, judicious additional labs, spend time on habits & prevention, etc. I do exposed skin, heart, lungs, belly. rarely a thyroid.(particularly the look in ears, check the throat song and dance is silly). A crusty peds NP made snippy comments repeatedly about how I didn't look in her ears on physicals so I put it on my stickynote. Dumb, but it takes a worthless second and her complaints took longer. With the skin exam of exposed skin, if I see AK's I'll freeze them, or consider derm referral if bluelight approrpiate. Time permitting, and derm referral NOT gonna happen, I'll do a TBSE particularly for someone with RF or AK's. I am typically discussing other preventive stuff as I do that portion of the exam. I also ask the ROS as I examine the particular body part, unless there is reason to be specifically concerned otherwise (hx CHF - I'll ask the CHF stuff in a chunk, etc).

[Savedfpdoc]

I want to go back to all the primary care doc's out there. For commercial insurance (BCBS etc), NOT medicare, NOT tricare, NOT medicaid-- tell me if you are paid for 9939X -25 and 99214. Example: I do a wellness exam, and evaluate new rheumatological complaints. Or new possible OSA or new mood symptoms, or have to start a med for HTN, or HLD. All of these things are examples where I'm doing a substantial additional E&M. My coder (and revenue people) are telling me that pediatrics and medicaid may cover this, but our payors do not. I've suggested we take some clear examples, bill,and follow the bill - they have asked tor reach out to the carrier instead and have not gotten back to me. FWIW, I am in the southeast -- when you reply (DM is fine) please let me know rough region you're in.

I’m in Texas. regular Medicaid will also allow it but managed Medicaid won’t .

[Savedfpdoc]

I want to go back to all the primary care doc's out there. For commercial insurance (BCBS etc), NOT medicare, NOT tricare, NOT medicaid-- tell me if you are paid for 9939X -25 and 99214. Example: I do a wellness exam, and evaluate new rheumatological complaints. Or new possible OSA or new mood symptoms, or have to start a med for HTN, or HLD. All of these things are examples where I'm doing a substantial additional E&M. My coder (and revenue people) are telling me that pediatrics and medicaid may cover this, but our payors do not. I've suggested we take some clear examples, bill,and follow the bill - they have asked tor reach out to the carrier instead and have not gotten back to me. FWIW, I am in the southeast -- when you reply (DM is fine) please let me know rough region you're in.

I bill the 9939x-25 and 99214 for all commercial insurances. Been doing that for years. Fyi for new patient..both codes can’t be new patient codes pick one to be new , usually works out better if the visit code is new rather than making the physical code new

[Kennyt7]

No such thing as a physical exam any longer. Blood Tests, listen to heart/lungs. END OF VISIT. No oral exam, no look in the ears, no look for skin lesions, no EKG, no inspection for ankle swelling, guess chest X-rays are gone, no prostate exam

[gap55u]

I want to go back to all the primary care doc's out there. For commercial insurance (BCBS etc), NOT medicare, NOT tricare, NOT medicaid-- tell me if you are paid for 9939X -25 and 99214. Example: I do a wellness exam, and evaluate new rheumatological complaints. Or new possible OSA or new mood symptoms, or have to start a med for HTN, or HLD. All of these things are examples where I'm doing a substantial additional E&M. My coder (and revenue people) are telling me that pediatrics and medicaid may cover this, but our payors do not. I've suggested we take some clear examples, bill,and follow the bill - they have asked tor reach out to the carrier instead and have not gotten back to me. FWIW, I am in the southeast -- when you reply (DM is fine) please let me know rough region you're in.

[nastle]

I turned down Locum once as they wanted to do ekg on every kid for sports physical! The office manager told me that’s what parents want
I said sounds like you need a different doc

[nastle]

Primary care here. I am increasingly parsimonious with labs (otherwise my inbasket is ridiculous and you chase a lot of BS). Like lordosis I follow uspstf (so a lot of healthy people get q5 glucose and lipid and that’s it). I tell patients that just because insurance may cover something doesn’t mean you need it. I will refer patients who are demanding unnecessary tests to “any lab test now” down the street (yes, you walk in, pay cash, and get what you want). Oftentimes from our meetings, I know that some insurers will NOT PAY US for something they deem medically unnecessary yet also NOT LET US BILL THE PATIENT (how does that work? Hence any lab test now). Lots of times once people know that unnecessary TSH is $300 and vitamin D is ditto…. Not so interested.

i have never ordered cbc cmp lipid ua tsh as my standard annual exam labs- even at beginning of career when that was more common. I have one dude who was a big executive and used to 3 hour executive physicals with a bunch of unnecessary crap. Over time, we have come to an agreement where I order a little more than usual but all is justifiable.

On PSA and MMG I have a relatively quick spiel. I keep thinking that I need a brief video to play after the MA leaves the room.

See the ND down the street and get your antimony and molybdenum blood levels

[nastle]

A real physical exam once a year seems very reasonable. Look for skin cancer, murmurs, bruit, etc. At the very least document what you actually did accurately so acute care physicians have a better idea what patients baseline exam actually is. I don't think a screening ECG in healthy patients at some point is unreasonable at all though repeating them annually as a matter of routine seems excessive. You could catch a long QT, brugada, HCM, etc before patient has a bad outcome from them. Additionally, it gives a baseline to compare to when the show up at the hospital with chest pain.

Is this based on actual recommendations of some medical society?

[MPMD]

I agree that physical exams are largely overrated. I can do about 95% of what I need to do with my eyes. The old ocular pat down will give you what you need to know.

if that isn't a sunny reference then we are in a fight

"wait..... ...... ...... ..... ...... ..... ..... .... he's clear"

[Savedfpdoc]

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).

Regarding billing modifier 25-my local coder pushed back initially saying “no ones ever done this blah blah”. So I sat down with her and the office manager and taught them how to bill. Most commercial insurance plans don’t have a problem with it. Also ok w traditional Medicare +\- supplement plan. Medicare advantage plans have given us a lot of headaches so not worth it to me to have that fight. Medicaid also has been a fight so I avoid doing it with those plans.

regarding 99215- I bill if sending to Er for hypoxia, chest pain, stroke etc. I also bill if I have multiple uncontrolled chronic conditions (atleast 3) that puts pt At significant risks. Also bill if a condition comes up and patient declines to pursue treatment or sending to hospice (ie 90 yr old w psa 70 who’s poa declines referral to urology). You also use the time (40+min ) to bill for 15 but my visits are never that long unless I’m I include time on phone w local nursing homes when I’m trying to admit a pt.

[AR]

However if I do a steroid injection for arthritic knee pain then I’ll for sure bill that.

Yeah, that's completely different. I don't think there is any disagreement on that scenario.

[Savedfpdoc]

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 love the 26 yr old male with no meds, who works out everyday. That’s an easy 99394. Keep em coming!

[Savedfpdoc]

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

Well you could always add the code for obesity counseling minimum 15 minutes to the physical codes…

[Savedfpdoc]

If the consensus that it is perfectly kosher to bill in that scenario, but no one actually does it, that is a little weird.

For those who work in big groups, is there no pressure from the billers and coders to bill for "I'm referring you to a dermatologist for this mole I saw on your annual visit"?

As a pcp, billing the separate visit will most of the time generate a long winded complaint by the patient at the next visit. Something I don’t have time for. So if it’s something minor like a referral for a suspicious skin lesion then I’m not gonna bill that. However if I do a steroid injection for arthritic knee pain then I’ll for sure bill that.

I work for a large hospital system, yes we do get pressure from admin to bill everything possible

[Savedfpdoc]

I still don't understand. In the scenario as described, would YOU bill or not. I'm not asking if it is theoretically possible. I am asking if you would bill it and if you would, what would your specific justification be (and what would you actually do in the visit).

So far, by my count, we have zero people who would actually bill for this.

It sounds like what you are saying, "That looks suspicious, I'm referring you to a dermatologist" is something that is acceptable to bill for, but you don't personally do it. Am I understanding you correctly?

Correct