Home Forums Discussions General Discussion Billing for physicals

Would it be cool to ask a billing question? I have a billing lady part-time, but she does not have all the answers. I'm basically curious how one deals with requests to bill visits for "complete physicals" for health screening purposes. I find often patients come in with lists of problems (or just one lenghty problem,eg tired all the time....), or come up with a number of problems during the history. I find pay for a routine physical to be dismal, and don't think it's fair to bill these as a "physical" even if the patient thinks so. What do you do? And let me know if there is a much better forum for amateur billers such as myself....BTW I'm a FP

We spend lots of effort to educate patients using handouts, mailers, and an electronic sign in the waiting room that a routine physical is just that... a routine wellness check. A number of our patients have a "wellness option" in their insurance, which for us pays fairly well. We review health issues, PHFSH, vaccination status, risky behavior, etc. with a goal of outlining what needs to be investigated further. It is then billed as V70.0 and coded as 99396. We are very clear that this does not include treatment services, prescription writing, labs beyond routine labs, etc. If a patient wants to discuss problems, engage in diagnostic services, or other treatment issues then they are told they will need to make an appointment for diagnostic and therapeutic services, as their insurance does not consider this part of a wellness visit. This future visit will then be billed at whatever level is appropriate. With enough "front end" warning, we do not get that much pushback.

If you do both, perform the preventive services "PE" and evaluate and manage medical conditions, you should be paid for both.
You would code for both the Preventive Services (using 99391 thru 99397 for established patients) and the E/M coded for the problem (99213 or the like), append the E/M code with a -25 modifier [Modifier -25: ?Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,?]... then make sure they are linked correctly to their ICD-9 code(s) in the billing program (the PE with v70.0 or the like, and the E/M with it's own appropriate code.. e.g. 937 or 401.9 or whatever it is you E&M'd). Most insurers will pay, but a reduced fee likely for the E/M.

You'd likely find these articles helpful:
www.aafp.org/fpm/2004/1000/p21.html
www.aafp.org/fpm/1999/0500/p18.html

but I'd encourage you and your billing staff to read and know a lot more on the subject... If you were to read through the last 10 years of Family Practice Management you'd find a lot of answers... and some untapped revenue... in fact, FPM has a site for their collections of articles sorted by category... here are the ones for "Getting Paid": www.aafp.org/online/en/home/publications/journals/fpm/gettingpaid.html

I'd read through and know each of the articles... and read through each month's "Coding & Documentation Q&A" section. Read the latest first, as every year there are changes.

Get paid for the work you do. Good luck, I hope this helps.

thanks so much,
Helene

thanks so much!

If you do the -25 modifyier, you will get varied responses from the insurance carriers. Some will simply not pay for the v70.0/99385 at the same visit as say a 99203. Period. BCBS is like that, at least Empire is.

Others will pay Half the 99203. That is, half of their rate. UHC, Oxford does this. A few may pay the full 99203 in this case. Aetna used to, but about 2 years ago they began only paying half like UHC.

I wish there was an answer to the "I am here for a physical but I have 7-8 other problems". I have tried every technique to get around it, but as a physician friend of mine says 'they will never understand'".

1. I tried to the do the physical and the problems all in one visit. In return I got chewed out by patients waiting behind the patient. I got chewed out by the patient later saying "I have no copay for my physical, why am I getting charged another 25 dollar copay" We explained to the patient that physical is physical only and problems visit are all the other problems she brought up. She called the insurance company to report me saying I didn't do anything for her despite me staying in the room for 1 1/2 hours with her. After we told we told her that she never paid the extra copay that day anyways, she hushed up and now is nice to me. She still follows me to this day and brings up 4-5 problems everytime.

2. I tried the "please schedule another appointemnt for all the other medical problems" technique. I got chewed out and was told that I was unethical, unprofessional and how dare I send her
out without dealing with all her problems.

3. I tried the , let me do the physcial 1st and then come back after seeing other patients to do the rest of the problems.
Pt left me and was upset that I made them wait so long in the office.

4. I tried the "tell front desk to tell pts this is physical only visit" Pts bring it up anyways in the office.

I wish there was an answer to all this.

There is: we call it a fellowship.

Believe me, I am totally sympathetic to what you say, and don't mean to sound glib about it. My fellow sub-specialists would shoot me for this, but the primary care providers should be the ones who get paid more, not us. Besides the higher fee schedule, we get another added benefit of extra years of training: namely, the ability to say "you will have to talk to your primary about that". That simplifies our job tremendously and sometimes I think it is worth way more than the money.

I tell this type of patient that if I record any other problems in my note, they will not qualify for their "wellness" benefit. I tell them that wellness visits are frequently audited, and they will have their claim denied, and be billed.

I ask them what would they like to deal with, problems or wellness? They can make the choice.

Also don't hesitate to charge patients for the extra time code.

Hey John, that's a nice one.

Alice much more often will now tell a patient who presents with problems at the physical that there isn't time to do both. I also try to catch this when I review our schedule or approve appointments, and will sometimes email a patient telling them that they will need to make a second appoinmtent to discuss the problems they mentioned that they wanted to discuss.

That sounds like a very rude patient. I have sometimes explained to them that they have to come back because insurance will not pay for it all at once and they usually understand, especially when I tell them I would hate for them to get stuck with the bill personally.

I also often just end up doing the acute/chronic visit and saving the wellness for later. I HAVE been calling in a lot of folks for their Medicare AWV and charging a nice fee for each one!

You are kind. I also like the benefit of being able to refer out if I want a problem addressed in more depth. You are the last stop for the buck, and have to find the answer.

Firstly, nothing will work on 100% of patients to your satisfaction, or theirs. That said:

1) Dont even try this doing number 1. Also, you'll need to dismiss this patient. And submit to the insurance company what you did address and your diagnosis. And that you referred her to a specialist and wrote a presciption. And if she doesn't pay, send it to a collections agency. We've done this.

2) Do number 2. On this particular patient, she'll need to be dismissed because her rudeness and disrespect "sundered the Dr./Patient relationship and you don't feel comfortable attempting to treat her." She can go tie up someone else's time. But explain to them that their insurance doesn't cover addressing issues in a "Preventive" visit--that is why the insurance companies call it "preventive" and not "sick". We do this.

3) Alice has done this a couple of times, but not anymore. Doesn't work. too bad she doesn't always listen the first time I tell her how to do things from the "business perspective."

It helps to give all patients a "policy summary statement" that explains some of these things and how you operate. They must sign to acknowledge that they received and understand it. If they don't, they go somewhere else. This shows that you told them all these things in advance (and you can do these things anyway, but it can help shorten any conflict). I am a firm believer in that a Dr. decides how he practice medicine (within the laws and stuff) and that patients need to adhere to that Drs policies or go find another who practices according to that patient's criteria. They can be someone elses problem, and be a deadbeat on someone else's accounts receivable.

Our policy statement actually has a paragraph about Preventive visits, Forms completion fees, no show/late cancellation fees, how to get your labs back, etc. And it has a statement saying that the policies do not cover 100% of issues, and may be changed without notice.