Physician Billing Tips: Knowing When to Bill Preventive and E/M Services Together

Let’s say a patient comes for a preventive medicine service and you end up also treating an acute or chronic condition of that patient.

So how do you determine whether to bill for the second service?

In other words, can you bill an office/outpatient service (CPT 99212-99215) on the same day along with preventive medicine service?

Along with other complications in physician billing like documentation requirements and frequently changing payors’ claim submission guidelines; coding and billing for evaluation and management services along with preventive medicine services create more confusion among the providers like you.

There are numerous myths around the billing process and healthcare leaders and advocates are working relentlessly to eliminate the challenges in physician billing services.

The Myth of Physician Billing

There is a misconception that physicians cannot bill for both preventive/wellness and evaluation and management services on the same visit.

The major confusion arises when physicians are instructed that they cannot bill for both services, or they can bill for both and only one will be paid. On top of this, they experience a pushback from the patients when they receive a billing statement with charges they did not expect.

Deciphering the Physician Billing Myth

Despite the myths to the contrary, physicians are allowed to code for both preventive and E/M services when they are performed in the same visit.

Motivated by a desire to avoid auditing, some physicians tend to avoid code for the services they provide. On the contrary, others are just unaware that the idea that physicians cannot bill for the services in the same visit is based on a myth, not a fact.

The significance of the problem is addressed by the American Medical Association (AMA), and the regulatory body is spreading the message through articles that provide clarification against this confusion.

It has been identified by the AMA that nearly 40% of physicians are burned out. The AMA is developing resources that prioritize the health and well-being of the providers.

According to the authoritative body, it is crucial to maintain accurate and complete documentation in the physician billing process to ensure seamless operations and revenue generation. Otherwise, you cannot bill properly and will be left with uncompensated care.

What Determines Appropriate Physician Billing?

In the case of billing for both preventive and E/M services on the same visit, the significance of the problem addressed, and the amount of medical decision-making required help determine how the services are most appropriately billed.

The CPT coding guidelines for physician billing provide clarification regarding this. If an abnormality is encountered or a pre-existing problem is addressed during a wellness visit, and the additional problem is potential enough that requires attention, then you can bill for both services.

You must ensure to implement modifier 25 within the process, which indicates that a potential, separately identifiable E/M service was provided on the same day as the preventive medicine service.

In fact, billing for Medicare and Medicaid requires that additional E/M services be billed separately from the preventive medicine services.

The Physician Billing Enigmas

Apart from coding and documentation challenges, physicians across the country face numerous challenges-

• Lack of patient education and engagement within the treatment process
• Absence of payment accessibility
• Inefficient customer support
• Filing multiple claims
• Duplicate billing
• High claim denials

Now here’s another tweak in the process! Commercial payors may not always reimburse for the preventive medicine and E/M services on the same visit, depending on the patient’s coverage and insurance benefit policies.

Whether the services are being billed to a commercial payor or Medicare or Medicaid, using modifier 25 appropriately will ensure accurate and timely reimbursements for your rendered services.

Read More:

In-House vs. Outsourced Physician Billing – Know All the Pros and Cons

As you run your physician practice, deciding between in-house or outsourced billing is crucial. Learn more about making the right choice.

Minimize Your Physician Billing Disruptions with Sunknowledge

With the raging competitive market, inflation, changing patient behavior and expectations, changing coding regulations, and claim submission guidelines, it is evident that you will feel overwhelmed by administrative tasks.

Along with these factors, consistent skill shortages and skyrocketing wages in the healthcare arena, make it difficult for the providers to sustain an in-house team for physician billing services.

Therefore, outsourcing physician billing services from Sunknowledge is a more feasible option for you.

Our team offers you immense expertise and experience of their huge talent pool and diverse challenges. In short, we bring a well-defined process to your table enhancing your practice’s performance with our comprehensive industry knowledge and cutting-edge technology solutions.

From patient’s insurance eligibility verification and prior authorization to denial management, collections, and payment posting- our team can provide you with an end-to-end solution for your physician billing services.

Not only that, but you can also leverage the benefits of dedicated accounts receivable managers who will look after your aging AR buckets and revive the lost revenue in no time.

Also, you cannot ignore the benefits of virtual assistance, a 10% buffer sustaining your productivity, immense data security, and industry-best processes in your practice.

Tackle your denials and boost productivity in your physician billing services by partnering with a reliable revenue cycle management company like us that boosts the overall performance of your practice in the long run.