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.
Important point. As journalists, we can’t take insurance literacy for granted. #MedX https://t.co/xSoTqYxMb4
— Charles Ornstein (@charlesornstein) September 16, 2016
daveNYC
So if you show up for the wellness visit and say everything is fine the visit is free, but if you mention that giblet X is tender or something, you may end up being billed for that portion of the visit?
Steeplejack (phone)
@daveNYC:
That’s why it’s called a wellness visit. Nobody wants to hear about any depressing illness stuff.
Eric S.
This was a surprise to me last year. I had my yearly visit about 30 days before my shoulder surgery. There was an evaluation to determine I was healthy enough. I was. No problems. The bill arrived some weeks after the surgery.
I don’t know if there is any data about this one issue but I would not be surprised to learn this is a point of consternation for people. They think Obamacare gives them 1 free visit per year but if you aren’t perfectly healthy open up the check book.
Richard Mayhew
@daveNYC: It depends. If you have a chronic condition (say Type 2 Diabetes) and say that you feel like you’re sugars are a bit off, that could be wellness.
but yeah, an annual PCP/Obgyn has to be pretty low key/check-in and say hi for it to be only a wellness visit.
I'mNotSureWhoIWantToBeYet
@Richard Mayhew: I visit my PCP twice a year – once for a “routine physical”, once for a followup. He’s trying to get my cholesterol down – specifically the “small sticky particles” type that apparently is the really bad type. I have a $n00 annual deductible with my BC/BS insurance. This week I had $1250 in bloodwork done per his order (I don’t know how much of that my insurance will cover and how much I’ll have to pay. My out-of-pocket share usually ends up being ~ 10-20% after everything is applied.)
Every time I visit his office they collect $20.
Is that because I haven’t crossed the insurance deductible threshold, or because the way they code things? Or because my insurance isn’t on the Exchange (but though work)?
I like him a lot because he’s very knowledgeable about internal medicine and has a good head on his shoulders. Visits almost always take at least an hour – he’s listens and talks a lot.
I don’t mind the $20, but it just seems weird that the ACA says one visit a year is supposed to be “free” but it never is for me.
Thanks.
Cheers,
Scott.
nonynony
So is this also why our local family doc’s office has a rule that the docs won’t discuss prescription refills during a wellness visit and you need to schedule a separate visit for that?
(They also won’t refill prescriptions over the phone – which I assume is because of prescription abuse and that the staff wants a blanket rule to follow and not a “these prescriptions need to be refilled in person with an evaluation”. But it is annoying to have to go through a whole visit just to get a refill of an emergency asthma inhaler.)
Yutsano
@nonynony: My doc does the same thing. His reasoning is to make sure there’s nothng bad that happened while taking the med even if it’s one I’ve taken for years. Personally I just eat the money because my doc’s worth it.
Richard Mayhew
@I’mNotSureWhoIWantToBeYet: Given the details in your comment, it seems like your PCP visit is being coded as a non-wellness visit due to the $20 co-pay but your plan might be either ASO or grandfathered so who knows… I can’t tell you what exactly is going on without actually seeing your policy.
Richard Mayhew
@nonynony: Yep… some docs will code with a modifier to split a visit. others will want a seperate sick visit. From an insurer POV it does not really matter. PCP visits are dirt cheap.
Wag
I am a PCP practicing internal medicine. I face this issue every day. The simple cases are the usual 30-year-old healthy patient with no medical problems. Does get billed out as a straight wellness visit.I utilize the ICD 10 code Z000 and bili the visit using the age-appropriate CPT code. any appropriate labs are linked to the wellness diagnosis. No co-pay involved for the patient.
If somebody comes in for a wellness exam and has an acute issue as described by Richard, again, it easy.I bill out the wellness portion of the visit as detailed above, and I bill out the acute portion of the visit using an appropriate evaluation and management (E+M) CPT code (in Richard’s case, would probably be 99213) with the appropriate 25 modifier.if the ankle sprain were more severe and required an x-ray, I would fill out a higher level CPT code. Similarly, if the patient has diabetes and her blood sugars have been out of control and I adjusted her medications and make a referral to endocrinology, this changes the tone of the visit from strictly wellness to one involving significant medical decision making, again prompting an E+M code with the 25 modifier.
The gray area occurs when the patient comes in for an annual wellness exam and has a single medical problem. An example might be high blood pressure well controlled on a single medication that doesn’t require any adjustment. In this case the medical decision making complexity is minimal, and I generally will bill the visit out as straight wellness with no additional E+M code.
I hope that this clarifies things.
Spike
This is why I don’t go to the doctor’s.