If you work in a practice that provides annual wellness exams, you’re probably a pro at coding and billing preventative visits, right? In fact, you’re pretty sure you could code these things in your sleep! You just put the correct 9939* code, include the 93000 for the ECG, address any other complaints the patient has at the time, and boom! See you next year! Right? Well, maybe… but the truth is there are a lot of rules dictating how to properly code and bill a preventative visit depending on the patient’s insurance and the services performed. Let’s break it down!
First of all, you select your appropriate 9939* code (last digit determined by the patient’s age) and continue coding the rest of the exam. The physician performed an ECG as a regular part of the preventative services, so you want to add that on there, as well.
WHOA PARTNER! It turns out ECGs are considered bundled into the preventative services and already covered under the 9939* code! Billing for it in addition to the E/M code requires unbundling these services by adding the Modifier “-25” to the exam code. According to CMS, this modifier means “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.”
Since this test is considered a bundled part of the preventative visit, it should ONLY be unbundled and billed separately when a valid related condition is present and noted on the claim. For example, for the ECG, you could unbundle it from the wellness exam if the patient also has palpitations or cardiac murmurs that are addressed during this visit. In this instance, the ECG would be considered separate and the E/M code (the wellness exam) would have the modifier added.
Sometimes a patient will come in for a wellness exam and also discuss acute concerns that they have at the time. This is another time for modifier 25! When billing, you would enter your 9939* code and be sure that the diagnosis codes that are associated with this service line ONLY fall under the wellness exam. Then, you would add the 9921* (last digit determined by the level of service provided) with the modifier 25 for the sick visit and be sure to ONLY attach the diagnosis codes that correspond to the sick visit.
Now let’s make it REALLY challenging! Let’s say a patient comes in for a wellness exam, but also has palpitations (needing an ECG) and a sore throat (acute concern). How would you code this? You know modifier 25 is going to be involved, but where? The correct way to code this visit would be as follows:
Wellness exam: 9939* associating only the diagnoses that correspond with this exam
ECG: 93000 only pointing to diagnosis for palpitations
Sick Visit: 9921* -25 only pointing to the diagnoses related to the sore throat
A word of warning about modifier 25: don’t abuse it! If you’re unsure when to use it, take the time to do the research because excessive use of this modifier is noncompliant and is often a big red flag for auditors!
Now that you are sure you’re coding your wellness visits correctly, you’re an expert on preventative exams! Oh, not quite. There’s one more major thing to remember with these visits: they have a specific time lapse requirement in order for them to be paid! For most insurances, a full year (or even a year and a day – yes they get that specific) must pass between uses of annual wellness codes or you will be seeing denials for “maximum benefit for this time period has been reached.” Womp womp. Some insurances have even started extending this benefit to one exam every two years, so check your patients’ benefits carefully and make sure you’re not scheduling too soon!
Once you know how to properly code AND how often to schedule these exams, you’ll be a preventative visit billing master!
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