Getting paid for prevention: Physicians facing coding challenges

Promises of payment for managing chronic illness and preventing disease have doctors struggling to track and bill for both "well" and "sick" care.

By Emily Berry — Posted March 24, 2008

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Health insurers are offering incentives to persuade members to see doctors regularly for "well visits" and to manage chronic illnesses. Physicians know that treating an acute problem pays better and is easier to bill than prevention.

Consultants and physicians say learning how to code, bill and schedule around prevention can bolster patient care and fair payments. But doctors often struggle with insurers to ensure that coding will be recognized and that they are paid fairly.

The difficulty in documenting and billing for preventive care and sick care is encapsulated in a common situation: A patient comes in for a checkup then mentions a symptom -- shortness of breath, chest pain -- that merits its own conversation and examination. Or, conversely, the patient comes for a specific treatment, but then wants to discuss how to stop smoking or how to avoid the heart disease that runs in her family.

"It's always a challenge when doing preventive care and disease care during the same visit," said Tom Weida, MD, medical director for Penn State Milton S. Hershey Medical Center's family practice in Hershey, Pa. Doing both kinds of medicine provides an opportunity, but also a trap. If you can get reimbursed only for a sick visit or an annual exam, which do you do, and which do you bill for?

"It's so hard to do the differentiation. ... We bill for pretty much what they came in for and gift the other things," Dr. Weida said.

To help physicians parse what specific type of care they give, the Current Procedural Terminology manual includes detailed guidance about preventive visits, screenings and disease management. But often the line between sick and well care is fuzzy, leaving doctors or staffs to decide how to bill.

Dr. Weida said he faces that dilemma daily. "Say I'm seeing somebody for high blood pressure or diabetes or cholesterol, and I notice you've turned 50. Well, I'm going to make a recommendation for a colonoscopy and for baby aspirin," he said. "I don't charge a preventive [code] on that because I didn't do what I know would be considered a full preventive visit -- I tend to use the preventive codes when I've done a complete physical."

It just isn't practical to separate the two issues into two visits, he said, and it's difficult to get insurers to pay for both if they happen on the same day.

"Unfortunately, a lot of times we just bill the one code," he said. "It's just too much of a hassle. It won't be a 'clean claim.' "

Erica Swegler, MD, a family physician at North Hills Family Medicine in Keller, Texas, said sometimes getting paid means asking patients to reschedule their second priority -- their annual exam or their specific symptoms or conditions. She said she would prefer to take care of all of a patient's concerns at once but feels hamstrung by health plans' reimbursement methods.

For instance, if she noticed an unusual mole during a woman's annual pelvic exam, she might ask the patient to come back later to have the mole removed rather than try do it in the same visit. That way, she is paid for both services.

That's only fair, she said, since if the patient's ob-gyn had done the pelvic exam and sent the patient to a dermatologist for the mole removal, the insurer would have paid two bills. "Family physicians end up giving away care," Dr. Swegler said.

But sometimes, rescheduling is not an option. If a patient has a checkup but shows symptoms of the flu, or if a mother brings in a child for immunizations but the baby has an earache, the doctor hardly can tell them to come back another time.

"That's not going to endear you to patients," said physician practice consultant Andy Zarick, MD, who was a family physician in Frederick, Md., for 18 years before becoming associate director at Navigant Consulting.

Paradoxically, segregating "well" and "sick" care conflicts with the preventive "medical home" that physicians like Dr. Weida want to create for patients. "I believe in doing today's work today," he said. "Why have somebody come back two times for something I can handle in one [time] slot?"

Coding: Modifier 25

There is a coding solution for that dilemma, called a 25 modifier. But doctors say the modifier, meant to signify a distinct treatment in addition to a preventive checkup or well-visit, too often is recognized by insurers in theory only, Dr. Swegler said.

While many payers claim to recognize and reimburse for the 25 modifier, they almost all edit them out with a coding scrubber, said Cheryl Gregg Fahrenholz, president of Preferred Healthcare Solutions, a physician practice management firm based in Bellbrook, Ohio. The upshot is that doctors get paid for a preventive visit or a sick visit but not both on the same day.

A major insurer disputes that. "Our current practice is that we reimburse both a preventive visit code and a sick visit code by the same provider on the same day," said Jill Becher, spokeswoman for WellPoint.

Doctors should find out which payers claim to recognize and reimburse for the modifier, and what documentation is required. Then be meticulous about writing down everything, Fahrenholz said. That includes not only what was discussed but also why and for exactly how long -- many preventive services are reimbursed by time, she said.

Dr. Zarick said doctors should be prepared to appeal a payment decision -- and have the documentation to back it up.

A new wrinkle has emerged. Patients with high-deductible plans often have 100% coverage for preventive care, which gives them an incentive to pack all their medical issues into an annual exam.

Scheduling a follow-up visit becomes not only a time issue but a financial one, as the patient will have to pay for the next visit, and the doctor will have to try to collect the charge.

Dr. Swegler said patients have scheduled preventive visits and come with specific complaints they want treated, without having to pay out of pocket. "It sort of puts you in this uncomfortable place." She tells patients, "That's a different sort of visit; we don't have time today to do those things." She reschedules and makes clear that she must bill specific treatments outside the annual exam covered by their plan.

James Little, MD, a doctor with Portland, Ore.-based ZoomCare clinics, said the group tries to cater to patients with high-deductible plans by posting online and on-site prices for patients paying out of pocket. The clinics, located in upscale shopping centers, tout their services as "health care on demand." The clinic offers incentives for patients to pay up front and in cash, so the tangle of coding and billing insurance can be avoided, he said.

"We tell patients what it will cost before they're seen," Dr. Little said. "That's really for people with high-deductible health plans. They're one of our key demographics."

Dr. Little said physicians in the group don't hesitate to ask patients to schedule a second appointment and offer online same-day scheduling.

Pay-for-performance is theoretically a great way to be paid for good medicine: managing chronic disease and preventing potentially deadly conditions. But many physicians still are only reading about P4P -- not participating in it.

Physicians who aren't yet on board need to take the first step of learning to track and document their work managing patients with chronic illnesses, Dr. Zarick said.

"Most of us are doing the work, providing preventive counseling, but we tend to forget to document it. The disconnect is mostly because we spend so much time taking care of our patients we frequently forget documentation. ... Physicians see paperwork as a necessary evil."

But if it's done right, tracking and documenting the care and monitoring of chronic disease -- such as when you measure diabetic patients' blood glucose levels -- can improve care, Dr. Weida said.

His department's family physicians have improved their management of diabetic patients dramatically with a P4P program done in cooperation with the center's endocrinology department, he said.

"Not enough providers are collecting the quality data," Fahrenholz said. "Five years from now, all reimbursement will be based on quality indicators." Though less than half of physicians participate in P4P, "It needs to not be ignored."

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Coding Prevention Thoroughly

It can be difficult to know how best to bill for preventive and sick care, especially when done the same day. Here are examples from the 2008 Current Procedural Terminology (maintained by the AMA):

Preventive counseling or risk factor reduction: These are face-to-face visits for "promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment. Preventive medicine counseling and risk factor reduction interventions will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter."

99401: 15 minutes
99402: 30 minutes
99403: 45 minutes
99404: 1 hour

Behavior change interventions: These visits are "for persons who have a behavior that is often considered an illness in itself, such as tobacco use and addiction, substance abuse/misuse; or obesity. Behavior change services may be reported when performed as part of the treatment of the conditions(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in an illness. Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection. Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a chance in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up."

99406: Stop-smoking discussion, 3-10 mins
99407: Stop-smoking discussion, longer than 10 mins
99408: Substance or alcohol abuse screening and intervention, 15-30 mins
99409: Substance or alcohol abuse screening and intervention, longer than 30 mins.

Modifier 25: Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service: "It may be necessary to indicate that on the date a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported."

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Experts' answers

It can be a struggle to get paid fairly for preventive care, despite health insurers' professed support for "wellness," chronic disease management and prevention. Here's what some physicians and consultants say can help ensure fair pay for both "sick" and "well" care:

  • Note a topic (for instance, smoking cessation) and why you're talking to a patient about it, what part of the visit you spent on it and for how long.
  • Expand documentation beyond individual charts. Track each time you read the blood pressure of your heart disease patients. Keep this in a database and establish protocols for seeing patients with chronic diseases. This will help you prepare for pay-for-performance programs.
  • Enroll in those programs. If you aren't ready, start tracking one preventive screening or disease measure, such as how many women 40 and older you see who have gotten a mammogram in the last two years.
  • Skip some paperwork and back-and-forth claim denials and appeals with third-party payers by posting prices for patients who pay up front in cash. Give patients an incentive by cutting prices by what you would have spent billing insurers.
  • Make sure patients know how broad you are willing to let your visits and conversations be. For example, if you have only 10 minutes for a patient's upper respiratory exam, ask them to schedule another appointment to discuss their risk for heart disease. This will ensure that you will have time to address it adequately and that you'll be paid for both the "sick care" and the counseling.

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