Q&A Billing An New Patient Visit & An Established Patient Vist - Same Day - One Claim

[TiffanyM]

Hello,

I am very interested in learning about providers billing a patient as new and established at the same time.

I work in the medical field. I came across a claim where the provider billed three lines of service. A 99386 New Patient - For the preventative visit - dx - Well GYN exam. On the next line they billed the Q code which is ok, and let me add, they also attached a 25 modifier to the 99386. On the 3rd line they billed a 99213 - Established Patient - Office or other outpatient viist, attached a modifier 25 to this code as well.

Can a provider's office bill this way - any provider seeing a patient for any type of visit?

Can they bill a new and a established patient E/M on the same claim?

The insurance company paid all 3 lines. They covered the preventative at the full allowance and then paid for the office vist @ 50%. Is this right? It does not seems to make since that the provider would bill both at the same time. The CPT and CMS guildeliness appear to agree that in "history" a patient is consider established once there as been a face to face.

Last thing, both E/M codes were attached to the same diagnosis code. The Well GYN Exam.

Thank you so much.. any help would be appreciated.

TiffanyM.

 

[Ruth Sheets]

This question was covered by Laureen Jandroep, CPC, CPC-I, in the October 2013 Q&A Webinar. Laureen talked about Preventive Medicine Services when a significant problem or abnormality comes up during a well care visit, and how if properly documented, the appropriate Office/Outpatient code 99201-99215 should be reported, as well as the preventive service. You want to have the physician document the new problem separately from the preventive visit note. Laureen recommended to search the payer's website to see if the payer had a written policy on reducing the 2nd E/M to 50%, otherwise consider appealing it.

Remember, if you'd like the full presentation on this, you can get it by joining the CCO Club. That will get you all the recorded webinar videos, answer sheets, and transcripts, and the corresponding CEU quizzes (available since May 2013).