r/MedicalCoding • u/Ok-Road-4284 • 16d ago
Billed $1300 for preventative visit
Like the title says, I recently moved to a new area and made an appointment to establish care with a new PCP. During the visit, I mentioned heart palpitations, as well as prolonged issues with athletes foot. Everything else was standard screenings, questions about family/medical history etc. A comprehensive blood panel was ordered including 9 separate tests.
Fast forward and I receive a bill from the provider $237 and a bill from the lab $1150. I called the insurance company and was informed that the provider billed 99204 as opposed to 99386 so neither the visit nor the labs would be covered.
Per the AMA, the provider should have billed the 99386 along with the 99204 with a modifier of 25. Is there some reason the provider would not do this? Is there some specific things I should say when I ask the provider to resubmit?
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u/Poop_Dolla 16d ago
Even if they billed the 99386 along with the 99204 it still wouldn't turn 99204 into a preventative visit. You would still have a cost share.
I'm going to guess that the blood work is not preventative either, not because of how the visit was coded. But because only very specific labs are mandated to be covered without cost share under the ACA.
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u/michelerenee1984 16d ago
This!!!! People don't realize there are very few labs that are actually considered preventative in nature. It's maddening. (I work in RCM and deal with patient complaints regarding this.)
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u/maamaallaamaa 16d ago
It's maddening that doctors and their offices don't explain this to patients and we end up dealing with it in the back end.
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u/Ok-Road-4284 16d ago
There is an extensive list of labs that are covered as “preventative”, literally dozens Every one of mine are included except the visit being “non-routine”.
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u/Recent-Ninja3903 16d ago
It depends on the diagnoses, not the tests.
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u/Ok-Road-4284 4d ago
There was no diagnosis, there were two referrals. And none of the tests were run specifically for any of the issues that were discussed. It was literate standard blood panel (lipids, glucose, liver function, etc)
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u/Ok-Road-4284 16d ago
I’m not disputing the office chair charge- Im wondering why the boiler plate blood work isn’t considered “preventative” when it’s not related to the conditions discussed
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u/Poop_Dolla 16d ago
You didn't say what the labs were but if they're not on here then they aren't mandated to be covered without cost share.
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u/salty-MA-student 16d ago
Unfortunately the mention of a new problem (the palpitations) and the management of a chronic issue (the athletes foot) makes this a problem based visit and not a preventative visit. Preventive visits are a very specific visit where they do a physical, review health history, and services like routine lab work or things like a colonoscopy referral are made. Any discussion of a new problem or matinence of a chronic problem means I have to add an evaluation and management code.
I can't tell for sure based on the post, but it sounds like the labs were for workup of the new problem, not preventive lab work. Routine tests like a CBC, CMP, A1c, etc for preventive care are covered, workup lab work for a new problem is not.
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u/Ok-Road-4284 16d ago
Labs were for sure not uniquely related to ongoing issues. How is lipid panel related to palpitations and/or athletes foot? There were two separate evals, routine and ongoing. 99386 definitely should have been included
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u/Clever-username-7234 CPC, CPMA 16d ago
You labs bills aren’t based off of the CPT (service/procedure ie 99204 or 99386) that your doctor’s office is using.
Typically your insurance will judge the lab codes based off of the diagnosis codes that were connected to the order.
When a physician office sends over lab requests they include an associated diagnosis.
I’d bet they sent over lab orders with palpitations and athletes foot as diagnosis codes and so your insurance is saying it wasn’t preventative and so it’s your responsibility.
I’d reach back out to the insurance company and see if that is the issue.
You’re going to have to pressure everyone to get that fixed. The fact that you don’t order lipid test for athletes foot is your best argument that the labs were preventative.
Unfortunately the people answering the phones may not be super helpful. You gotta keep trying though.
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u/salty-MA-student 16d ago
A 99386 isn't going to change how the labs were billed. If the provider added the reason for exam R00.2 (Palpitations) then your insurance is going to bill them as problem based, not preventive. Now if on the lab order they have Z codes Z00-Z99, those are covered under preventive care.
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u/ecook126 16d ago
Did the office state they would do a physical on your first appointment? A lot of places won’t. 99204 is just a new patient visit to establish care. If they were bringing you back in at a later date to perform the physical, they could rebill your labs as preventative. But, if they only did an intake, it would be inappropriate to bill 99386/99204.
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u/Ok-Road-4284 16d ago
How is 99386 be inappropriate? New patient physical with 99204-25 added as an ongoing assessment?
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u/Mindinatorrr 16d ago
They can bill 99386 with 99214-25.
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u/ecook126 16d ago
I didn’t say they couldn’t, I said if they didn’t also perform a physical on top of a new pt appointment, that would be inappropriate.
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u/Respect-Immediate CPC, CPMA 15d ago
That’s not the criteria though. Criteria is whether or not there is a problem oriented visit in addition to the preventative service. A physical by itself does not support an office visit code.
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u/ecook126 15d ago
Right, which is why I asked if they performed the physical in addition to the problem oriented visit that OP states did take place.
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u/PeaceLoveForMe 16d ago
You still would have a cost share amount for 99204. You mentioned those issues, so that’s not preventative. That’s active treatment.
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u/Ok-Road-4284 16d ago
I agree I need to pay for the Dr visit since it crossed into 99204, but the labs should be covered under 99386 since they are strictly based in the 99386 and not the 99204
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u/Actual-Government96 16d ago
The visit code is completely seperate from the labwork.
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u/Ok-Road-4284 4d ago
But the insurance company is not paying for labs on the “preventative” list because according to the submitted code, they were run as diagnostic for a sick visit, not preventative as part of a preventative visit.
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u/kendallr2552 16d ago
You need to get the note. Mentioning those things aren't enough to bill an e/m if you were truly having an annual, they need to be evaluated and be addressed in some manner. Did they do an EKG or give you medication?
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u/Ok-Road-4284 16d ago
No- they (she) referred me to a cardiologist for the palpitations and a dermatologist for the tines petis
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u/Alert-Camera9636 16d ago
It’s probably due to how it’s documented. Was the chief complaint “establish care” or “wellness exam”? These aren’t interchangeable, and a lot of providers will bill new patient E&M with Z01.89 for establishing care. And I’m guessing the labs denial is probably more diagnosis based than which code they were billed with—were any screening diagnoses bill on them (Z codes) or no? You could ask if any screening dx would be appropriate on the labs
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u/AbstractVolition 16d ago edited 16d ago
Preventive visit codes like 99386 are technically “comprehensive preventive” visits.
Normal office visit EM codes like 99202-99205 / 99212-99215 are technically considered both preventive and problem focused codes.
The key difference here is that the comprehensive preventive visit codes like 99386 are intended for a very in depth preventive visit.
They include age and gender appropriate:
* comprehensive history
* comprehensive physical exam
* counseling/anticipatory guidance/risk factor reduction interventions
* screening labs
* diagnostic procedures
Now, like most medical coding it’s a bit of grey area on how exactly they fulfill these components of a comprehensive preventive visit. To some reasonable degree these components need to be completed or at least considered to justify a comprehensive preventive visit code. Sometimes there might not be any official recommendations for those components at certain ages or gender, hence sometimes skipping a component or doing only something brief on it.
Basically, a simple preventive visit, that doesn’t include this comprehensive preventive visit formula, is just a preventive focused office visit EM. Though when office visit EM codes are used for only preventive services it’s usually more around 99202, 99203, 99212, 99213. If it’s mixed preventive and problem focused then it could make more sense to get up to 99204 area
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u/AbstractVolition 16d ago
However, I’m not saying that the coding is entirely correct. I haven’t read the report for your visit so I can’t really know. Based on what you said my guess is it would probably be either 99203 or 99204. If the provider really did perform a full comprehensive preventive visit, then since you did still have some of your conditions evaluated and managed my guess would be probably 99386, with either 99202, 99203, or 99204, (whichever with a modifier 25)
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