Do you ever have a circumstance when you can bill a preventive care and a sick visit during the same encounter? If so, are you documenting and coding correctly? This is often a missed opportunity. Both visits may be documented in the same encounter note and must justify the codes billed. This type of billing is common with PCPs when the insured patient has an annual physical examination benefit with their insurance plan that is of no cost to them. It is important to verify the patient’s benefit at each visit.
Circumstances when this type of billing may occur:
- Patient doesn’t have a PCP and presents for a sick problem and wants to establish care
- Is it time for the patient’s preventive care visit? If not, the patient may receive a bill for this service.
- Patient presents with a problem and it is time for their preventive care visit
- Patient will have a financial responsibility for the sick visit as per their insurance plan.
- Patient presents for their preventive care visit and the provider identifies a problem that needs to be addressed. Example: chronic conditions or problems that require RX management.
- Be aware that the patient may have a financial responsibility for the office visit billed.
Often the provider documents an A/P that addresses both the preventive care and sick visit. The following A/P along with the full physical examination documentation, not shown here, justifies a preventive care visit along with a sick visit for the two problems addressed. Billing both codes shall be supported by the documentation and will recognize the provider’s work performed.
EXAMPLE: Assessment & Plan
1. Health maintenance/Routine general medical examination (preventive care)
- Glycosylated Hemoglobin (A1C)
- Thyroid Stimulating Hormone
- Vitamin D, 25-OH
- Lipid Panel (80061) (Total Cholesterol, Triglycerides, HDL)
- Magnesium
- Hepatic Function Panel (80076) (ALB,T.PRO,BILI T,BU/BC,ALT,AST,ALK PHOS)
- Basic Metabolic Panel (NA, K, CL, CO2, GLUCOSE, BUN, CREATININE, CA)
- Cbc with Diff
Advised to engage in moderate-intensity physical activity for 150 minutes per week to include muscle strengthening/resistance training. Advised to consume half a plate of fruits/vegetables, a quarter plate of protein, and a quarter plate of carbohydrates per meal. Limit intake of sugary drinks, white rice, white bread, bacon, cold cuts, butter, and trans fats, and to aim for a daily protein intake of 80 to 100 grams.
2. Anxiety- chronic, uncontrolled. (sick diagnosis)
Reports episodes of heart racing and undiagnosed anxiety. Exam findings include normal heart and lung sounds. Refer to Psychiatry Adult for cognitive behavioral therapy.
3. Esophageal dysphagia -- acute, uncontrolled (sick diagnosis)
Reports occasional difficulty swallowing, with food getting "stuck" in his throat. Referred to gastroenterology for EGD to investigate possible esophageal strictures.
IMPORTANT - Be sure to associate the preventive care diagnosis to the preventive care code and the sick diagnosis to the appropriate office visit code. View the tip sheet for instructions here.
Revenue Cycle Financial Clearance working in conjunction with Coding Education to bring you information to manage the patient experience for all patients at UTMB. We are dedicated to the education and success of all UTMB providers. Please contact The RCO Financial Clearance and Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |