By this point in the soccer season, something usually hurts. Last night, I was running a line on a bad field and tweaked my ankle. Thankfully I did not roll it, but I jammed it on a divot. I iced it last night. I’m keeping it elevated and compressed today. And once I’m done with the weekend where I’ll have it wrapped by the trainer before each game, I have a couple of days before my next game. I’ll be fine by the middle of next week.
I also have my annual PCP well visit scheduled at the end of the month. Per PPACA this is a zero cost-sharing service as long as it is coded as a well visit. I’ve been seeing Dr. Walker for years now. We have a routine. He’ll suggest that although my waist line and body fat percentages are good and my aerobic capacity is strong, I could afford to drop a couple pounds. I’ll agree that ideally that would be nice. He’ll ask about my parents and I’ll ask about his kids. We’ll talk soccer as he plays on one of the older beer league teams and then he’ll ask if there are any other problems that he should know about and any lingering injuries.
I’ll probably mention that my right ankle is acting up again and it has been the usual suspect since 2013 when I rolled it hard during a game. He’ll ask me to move it around. Then he’ll twist it with his hands and say that it still feels good enough and that once I’m able to rest, I’ll be fine. And then he’ll remind to get my lab done before I go to the front desk and schedule my appointment again for 2017. He’ll then spend a minute or two talking into his tape recorder as he organizes his notes.
When he has his coder create the bill, the coder has choices to make. The first part of the bill is simple. I had a routine wellness visit with no cost sharing. However the coder has a second choice. Was the ankle an Evaluation and Management visit?
It really depends on what Dr. Walker put into his notes.
From a strict billing perspective Dr. Walker received a relevant medical history (persistent ankle problems since 2013 and the most recent event that led to a re-tweaking), he performed basic testing and then made a relevant medical decision to recommend that I rest my ankle once the season is over. That combination of activities is a sick visit that should be charged cost-sharing. If the notes support that, the biller will most likely add a modifier code to the claim that splits the visit into a non-cost-shared well visit and a cost-share applicable sick visit.
I know that because I spend way too much time thinking about claims. Most people who are going on their well visit don’t know that if they actually talk about an acute problem that they’ll be at risk of transforming the visit from a “free” visit to a cost-shared visit.
— Charles Ornstein (@charlesornstein) September 16, 2016