Coding Questions: Billing a Physical During a Follow-up

Q: We have a patient who is coming in for a hospital follow-up and would like a physical at the same time. Are we allowed to bill both? He isn't a Medicare patient.

A: The first place to look for something like this is typically the Correct Coding Initiative (CCI) tables. Although you specify that this is not a Medicare patient, most private payers adopt this standard set of edits, and then add more exclusions for various codes or code combinations.

In CCI the general health maintenance codes (99281 – 99397) are not listed as mutually exclusive with the Transitional Care Management (TCM) codes 99495 and 99496. That said, we have no way of knowing what any individual payer will do in this situation.

These are distinctly different services and should fall under the general provisions of modifier 25. Per CCI the 99495 or 99496 cannot have a modifier 25 appended, which may be a hint that it is intended to be billed alone.

But a 99396 for example can take a modifier 25. So the combination 99396-25 and 99495 may well be acceptable. This would also be supported by the difference in diagnosis codes for the two services: the preventive code would most likely have a Z00 series code, while the TCM code would be linked to the specific problem diagnosis codes.

The CPT manual only states that the 'same individual may report hospital or observation discharge services,' but makes no mention of other EM codes or modifier 25.

So there are no obvious contraindications to using these codes together, but coverage will still be up to any given payer.             

Q: Some of our physician's document in the ROS section of the EHR that the ROS is "Negative except noted in the problem list." How correct or incorrect is this?

A: That is a new one. They may have been given some guidance to this effect but it doesn't sound like any standard guidance. It certainly doesn't come from the Federal Documentation Guidelines.

But it would seem to be of no real value as far as the ROS goes. The problem list typically doesn't have ROS data in it – it's a problem list. There are EHR's where providers can edit the problem, list and may actually document the status of a given condition in that part of the chart – but it's not a great idea as a rule. That's because those lists are often not updated, have old or outdated diagnoses, and to use that part of the chart for ROS info seems a step to the side. Why not use the ROS area?

Common sense would suggest providers need to do what it says in the guidelines....if applicable say 'ROS otherwise negative,' after giving a couple of relevant positives and negatives. Those specifics are the medically necessary and relevant clinical information, and 'o/w' part covers the rest. Don't do something unusual here – stick to the basics.

Q: Can I bill a G0438 or a G0439 with a Depression screening code G0444?

A: You cannot bill a G0438 and a G0444 as the G0438 includes a depression screen by standardized instrument. The G0438 requires the depression screen, an assessment of functional ability and level of safety and the detection of cognitive impairment.

The G0439 subsequent Annual Wellness visit however does not include the requirements for the depression screen or the assessment of functional ability and level of safety. It does still require the detection of cognitive impairment and other listed elements. So yes, you can bill the G0444 if performed and documented with the G0439.