E&M and preventative

New patient makes appt for physical, has HTN, high chol and DM. I do the physical and address the chronic problems and prescribe meds, order tests, old records, etc. I want to code a new pt preventative 99386 and an E&M new pt 99203-25. My biller says they only pay if I bill the E&M as established even though the patient is new, so I choose 99214-25. Is this another "makes no sense but if you want to get paid then you do it"?

E&M and preventive service

The insurance company only pays one new patient visit/physician (or group of same specialty MD's). She's right: bill the preventive as new and the problem oriented visit as established.

Consistently Inconsistent

This is another example of how health plans are consistently inconsistent! Some will pay both the Prev Med and the Office Visit as New and others will pay one as New and the other as Established. It is what it is; however, when you read the definition in the CPT for Prev Med and see that medical issues can be coded on the same day with the -25 modifier, you will see that they include the "New" patient O/V codes as an option. So, yes, the health plans should follow CPT; however, they often don't and make up their own "policies" that differ from CPT rules.

This is something that I think that needs to be addressed in health reform to help cut provider costs in trying to deal with all these inconsistencies! Wouldn't it be much easier if all health plans had to follow the same rules?

Charlene Burgett, MS, CMA (AAMA), CPM, CPC, CMSCS
Administrator, North Scottsdale Family Medicine
POMAA National Advisory Board (www.pomaa.net)
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