Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

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FOBT (Fecal Occult Blood Testing) Coding Fact Sheet Sunday, Aug 12 2012 

Erica Schwalm graciously allowed me to post her coding fact sheet for Fecal Occult Blood Testing. Thank you, Erica!

“My office was having a lot of billing errors related to billing for FOBTs so I made this coding fact sheet to help everyone (physicians and coders) out!  Perhaps it will be of some use to some of you as well.  82270 can NOT be billed for FOBT done via DRE, but 82272 can…  I was seeing a lot of providers trying to bill 82270 with wellness visits when they shouldn’t have been and then, on the other hand, I found many “problem” FOBT’s (82272) that were never billed for when they should’ve been.”

Erica D. Schwalm, CPC, CPC-GENSG, CMRS

http://www.ericacodes.com

FOBT (Fecal Occult Blood Testing) Coding Fact Sheet 

There are two types of FOBT – Screening (82270) & Diagnostic (82272)

1.  The SCREENING test is covered yearly for those aged 50 and over.  This is a preventive test done in the absence of any signs or symptoms.

The patient is given “Stool Cards” to take home and collect three consecutive specimens.  When complete, the pt sends the cards in for testing.  Once testing is complete, then we can bill for CPT code 82270Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection).

We cannot bill for the test when the pt is given the cards, only once they are returned and interpreted.

We cannot bill for screening FOBT when done during a rectal exam because only one sample is tested.  This does not meet the qualification for the code.  This method is considered to be included in the payment for the office visit.

The only acceptable diagnosis for this is V76.51 (Screening for colorectal cancer)

 

2.  The DIAGNOSTIC test is covered when medically necessary for signs & symptoms without regard to patient age or frequency limitations.

The patient may be given “Stool Cards” to take home and collect 1 – 3 specimens.  When complete, the pt sends the cards in for testing. Once testing is complete, then we can bill for CPT code 82272Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.

In some situations, the physician may perform the test during a rectal exam (e.g. pt comes in c/o abdominal pain and tarry stools, physician would need to know immediately if there is active GI bleed).  Unlike code 82270, this one CAN be billed even when only one specimen is tested.

Do not use a v-code.  Use the sign or symptom(s) that prompted the test (e.g. rectal bleed, abdominal pain, etc.)

Gardasil (HPV Vaccine) approved for boys/young men Sunday, Aug 22 2010 

In the past several years, the FDA has approved new immunizations in an effort to prevent various illnesses, including sexually transmitted diseases that could result in cancer.  Once such vaccine, Gardasil, is “currently is approved for use in girls and women ages 9 through 26 for the prevention of cervical, vulvar and vaginal cancer caused by HPV types 16 and 18; precancerous lesions caused by types 6, 11, 16, and 18; and genital warts caused by types 6 and 11.”  In October 2009, the Food and Drug Administration announced that it approved the use of Gardasil vaccine for boys/men between the ages of 9 and 26 years of age, as well.

According to About.com, in providing Gardasil vaccines to young men, “the result would likely be:

  • less spreading of HPV
  • hopefully, fewer cases of cervical cancer in women
  • perhaps, a decrease in other types of cancer”

HPV can cause genital warts in men that may lead to several types of cancer, including oral, penile and anal cancers.

As with most new immunizations, it can take up to a year for this to process through to the insurance companies before they create policies to cover the vaccines.  At this point, Gardasil is covered by most health plans for girls and young women; however, the same is not true for boys and young men.  The Gardasil vaccine is quite expensive and requires a serious of three vaccines over a six month period that could cost in the range of $650-800 for the entire series.  It is recommended that you verify with your health plan, beforehand, whether or not they cover this vaccine, especially for the male gender.  If they do not cover this vaccine, it will result in the cost being transferred to patient responsibility.

FDA announcement:  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm

About.com:  http://cancer.about.com/od/hpvvaccine/a/hpv_vaccine_boys.htm

New Trick by the Health Insurance Industry Tuesday, Nov 3 2009 

Imagine that you are an independent contractor for a company that pays you a specific rate for a specified amount of work; however, if you do more than the specified amount of work you would receive an additional amount.  Now, if you were to do that additional amount of work separately you would receive 100 dollars.  But, if you do that additional amount of on the same day as your normal work load, you would receive your normal pay for your normal work load and 50 dollars for the additional amount of work.  Would that be acceptable to you?

To illustrate further, I do my work and earn $100.   Tomorrow, I fill in for someone else and do their work and earn $100.  Okay, that seems fair. Tomorrow, I not only do I do my job, but I also completely do someone else’s work.  As an independent contractor, should I receive $100 for my normal work and that’s it?  Should I receive $200 for a double workload?  How about if I only get $150…$100 for my work and $50 for completing someone else’s job?  I think many of us would say that I should receive $200!

Unfortunately, many physicians are experiencing the $150 example from health plans when it comes to providing medical care on the same day as a preventive medicine visit.  According to universal coding principles, it is expected that a physician will code an evaluation and management (Office Visit) for diagnostic (medical) issues when done on the same day as a preventive medicine (complete physical).  One of the primary reasons is so insurance companies do not have to reimburse for services outside their reimbursement policies; for example, if the patient does not have preventive medicine benefits but comes in for a physical, the physical can not be coded as a covered medical benefit just to get  paid.

In physician coding, we are trained to code all services accurately to represent what actually was performed and documented so as to not open the practice up to the risk of fraud and abuse allegations.  In theory, one would think that if there is a universal coding policy, then the service should be reimbursed in a consistent manner; however, this is not the case.  What we are seeing is that the majority of health plans will pay the problem visit at 50% and the physical at 100% (there’s your $150!).  A few others will not reimburse the problem visit at all on the same day as the physical (you only get $100…double the work at the pay of one job!).  Consequently, many physicians are telling patients that they cannot have both services performed on the same day, thus the physician is able to get full reimbursement for each service (aha! that’s where I put my $200!).

It is inconvenient to the patient to make two appointments; but with the increasing expenses that physician’s practices are having to absorb, it is just not possible to throw away all or half of a reimbursement.  In addition, it is inconvenient to other patients who are not able to get in to be seen because of the physician’s full schedules…or doing in two visits that which he can do in one.  Understandably so!  The physician should be reimbursed for all of his services fairly.  This will allow the physician to be able see additional patients who require medical attention and not play insurance games!

Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009 

Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com

by Gary Harper/3 On Your Side

August 5, 2009

A Valley woman says she has a billing problem with her doctor’s office.

The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.

The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?

Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”

So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”

Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.

She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”

Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”

The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.'”

Patient Notice for Preventive Medicine Visits and Office Visits Thursday, Jun 11 2009 

This is a notice that we have in every exam room explaining to patients how physicals and medical visits are coded and the expectant results by the insurance company.

ATTENTION PATIENTS:

If you are here for a scheduled preventive medicine visit (i.e. well-visit, Prev Med, or yearly physical exam) this visit will be submitted as a preventive exam to your insurance. Depending on your health plan’s policy, your insurance may or may not cover this visit. Not all insurance companies cover well visits; or, you may have a maximum annual cap for well benefits that is less than our charges.

If during the course of your preventive exam, the physician addresses and documents a problem-related issue (i.e. hypertension, depression, diabetes, pain, acne, etc.), you may also receive an office visit charge as well. In addition, your insurance may require you to pay two co-pays for today’s visit because of the well-visit and a problem-visit charge on the same day.

Some health plans have forced us to schedule the physical on a different day than the well-woman (annual female exam with pap), due to the fact that they will not pay for both on the same day. Please be assured that we understand that this is not convenient for our patients. We are sorry for the inconvenience.

Lastly, the physician assigns codes according to the services he/she provides. The doctor cannot alter the coding submitted to your insurance in order for your insurance carrier to make payment.

If you have any questions, please contact our billing department.

Well-Woman Coding Wednesday, Apr 22 2009 

Starting January 1, 2009, BCBS will not be reimbursing G0101, Q0091 or the S0610-2 codes when done with the preventive medicine visit. We have now changed our policy that we will not perform the well-woman visit on the same day as the preventive medicine visit in response to a few of the insurance companies’ new policies. Here’s my response to Physicians Practice on this, it’s not short, but this is my view…

2) ASK THE EXPERTS: Two for the price of one?

QUESTION: Concerning billing for pelvic exams and Pap smears, are they nonbillable services that the physician must just increase his E&M charge to cover? ANSWER: Medicare covers both, with certain limitations. The frequency is determined by risk. To bill Medicare, use a screening diagnosis code, usually v76.2 or v76.47. The procedure is billed with HCPCS codes. Usually, other payers do consider a Pap to be part of a preventive exam — and so also part of the E&M code. There are some payers in the country who will pay separately for the collection of the Pap smear when performed during a routine preventive exam. Usually they provide written instructions to bill the Q0091 as an additional code. If the payer has issued that instruction, report the code. — Pamela Moore, PhD

Dear Editor: Regarding the answer provided to the “Ask the Experts” question, there are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others will pay certain ones with a preventive visit (9938x-9939x series) and others will not. Some will only pay the HCPCS codes above with an Office Visit (9920x-9921x series) and others will not. Usually health plans are not forthright in communicating their reimbursement patterns and the provider will need to do their own research and billing trials based on health plan.

Billing the Q0091 and/or the G0101 with a Preventive Medicine code is somewhat controversial. You will find some people who are adamantly against it. I personally feel that because the Preventive Medicine codes are only differentiated by New and Established patient and by Age; therefore gender specific further evaluation should be reimbursed on top of the Preventive Medicine visit. So, basically, a female preventive medicine exam reimburses the same exact amount as a male of the same age. However, a well-woman exam is more labor intensive, greater risk and utilizes more supplies and time than what would be included in a well-man exam. Why shouldn’t we receive a higher reimbursement to cover the costs of a breast and pelvic exam and obtaining pap smear? We may not have to pay for the thin-prep containers, but we do have to pay for the speculum, spatulas, brush, gloves, lubricant, gown, etc.

In addition, many women choose to see their PCP for the general physical exam and go to their gynecologist for the well-woman part of it. Should the gynecologist use the Preventive Medicine code for their portion of the exam….even though they don’t go beyond the genitourinary system? The gynecologist should be able to code the G0101 and the Q0091 (and possibly an OV code if there is a problem-oriented issue discussed), leaving the Preventive Medicine code to the PCP. Now, what happens if the health plan will never pay the Q0091 and G0101? The gynecologist will not get paid!

I typically suggest that the Q0091 and G0101 code be coded to every health plan and not to worry which ones pay and which ones don’t. It’s better to code it and get paid for one or both than to not code and not get paid on either. For example, for United Healthcare, I recommend that our physicians perform and code a Preventive Medicine code first. During that visit, the physician should perform the basic preventive medicine exam and order the blood work and any other testing that is necessary for age and gender. Have the patient return to the office on another day and go over the results of the testing that has already been done, address any problem issues, and then do a well-woman exam…code the OV(with modifier -25) and the G0101 and Q0091 codes for that second visit. I understand that it is inconvenient for the patient and we try to make things convenient; but this is what the health plans require. I have actually had a particular health plan state that this is the way we should code, regardless of it being inconvenient to the patient. It’s too bad, but physicians have to start looking at their bottom line!

I definitely advise people to look into the S0610 and S0612 for the gynecology visit, especially with BCBS. They will find the reimbursement rates are very good. Other health plans will reimburse the S-codes; however, Medicare will not. We are currently testing variations of coding combinations by payer to determine which is the most appropriate combination to bill by payer. This does take a lot of time on your staffs part, but it could be very cost effective if you are able to actually receive reimbursement for the services you are providing. When using the S0610/S0612, do not use the G0101 code, because they are pretty much the same code. However, I would code Q0091 in addition to the S-code if a screening pap smear was obtained.

These codes are controversial in the “coding” community; however, I firmly believe that there should be increased reimbursement for the well woman preventive exam. It truly troubles me that the Preventive Medicine codes are reimbursed the same for male and female patients. We have already established that it requires more time, more risk and requires supplies to perform the breast, pelvic and pap. The fact that some health plans want to bundle that into the Preventive Medicine exam is ridiculous! One of my goals is to inform more physicians about this and, eventually, the more physicians who take a stand, the more power we have to change the reimbursement by the health plans!

There are many physicians, billers and coders, who just accept whatever they can get as far as reimbursement. There is not enough time in a day to do appeals and really learn the various coding policies. One of the worst mistakes a physician can do is to under staff the billing department and/or not have billing people who have the means (resources) to stay abreast of all the inconsistencies in billing. The other problem that I see in our industry is that, coders especially, see only in “black and white”. There is no “outside the box” for them. This is a detriment because, as we can see, the health plans do not know “black and white”. Each health plan develops their own reimbursement policies that go against what coders learn. There are Medicare guidelines, CPT guidelines, BCBS guidelines, UHC guidelines…I think you get the picture! When I talk with my physicians and billing/coding staff, I will clarify that I am referring to one guideline versus another.

Now, until all physicians, coders and billers can get on the same page and insist that the health plans reimburse for the services that the physicians perform, we are going nowhere and the health plans are holding the cards! I applaud physicians and their staff for seeking information and building their understanding of this part of the industry.

Thank you for allowing me to present by opinion on this subject.