“I recently saw a new patient with Oxford insurance for a tinea problem. A prescription was given and options for additional treatments were discussed. We billed his insurance for an initial office visit. The visit was allowed by insurance and the payment was applied to his deductible. He was billed by us. He checked with Oxford and is now telling us that “preventive” care is not subject to the deductible and would like me to resubmit to Oxford telling them that the visit was for “preventive” care. My opinion is that “preventive” care does not really apply to a specialist and that I could not undo what I already submitted. Can we bill for “preventive” care and, if so, is it possible to resubmit the claim?”
So, a new patient was seen with good, old Oxford Insurance. The patient had a tinea problem. How was it treated? The patient was provided with a prescription for the tinea problem and was provided with options for additional treatments. How should this be coded? For an Initial patient E/M service using the 2021 E/M service guidelines, this should probably be billed as CPT 99202. The claim was submitted, allowed and was applied to the patient’s annual deductible. Since the patient is responsible for the deductible, he was sent a statement for the amount that was owed. End of story. Or is it?
The patient calls Oxford Insurance and the patient is telling the provider that “preventive care” is not subject to the deductible and the patient would like the claim resubmitted to Oxford telling them that the visit was for “preventive” care.” Unless the patient is a billing and coding expert and knows exactly the difference between “preventive care” and a traditional E/M service or even what “preventive care” is, how can you rely on any information that the patient is providing you with? As the provider, you don’t even know what the patient told the insurance company and visa versa.
Coding Guidelines for CPT Preventative Medicine Services
In CPT, preventive medicine services are represented in evaluation and management (E/M) codes 99381–99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.
CPT codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.
Documentation requirements for a preventive visit such as an “annual physical” include an age- and gender-appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions. CPT codes for immunizations and ancillary studies such as laboratory and radiology are reported separately. The preventive medicine comprehensive examination documentation requirements represent significant work for the physician or other provider, and payer fee schedules appropriately reflect that work.
Is this what the patient was provided with for a tinea problem? ABSOLUTELY NOT! CPT 99202 is the E/M code that should be billed. The amount allowed went to the patient’s deductible. The patient owes the balance due.
This is my opinion.
Michael G. Warshaw
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