[Ohioaap-practicemanagers] Reimbursement for simultaneous "well visits + acute" clinic visits

[Combs, Frank]

Good afternoon everyone,

I apologize if someone has already addressed this.  This is a source of frustration for many practices.  UHC will sometimes tell practices that the reason they reduce the acute visit by 50% is because the provider only has to take the patient history and complete the exam once not twice.  Because of this some practices will see the patient for the acute visit and reschedule for the well visit.  Unfortunately, as you mention, this may mean a missed opportunity especially for our adolescent patients.

The CPT coding guidelines are silent to this interpretation that UHC is taking.  Coding experts will often recommend that you document the well visit and the acute visit separately and of course code the modifier 25 as you mention below.  This does not guarantee full payment for both however there are some payers that will reimburse fully for both (e.g. Anthem used to reimburse both).

I wish I could share better news.  Other practices may approach this differently, this has just been my experience.

Warmest regards,

Frank

From: Ohioaap-practicemanagers [mailto:ohioaap-practicemanagers-bounces at lists.deltaforce.net] On Behalf Of Michele Dritz via Ohioaap-practicemanagers
Sent: Thursday, April 20, 2017 8:57 AM
To: ohioaap-practicemanagers at lists.deltaforce.net
Subject: [Ohioaap-practicemanagers] Reimbursement for simultaneous "well visits + acute" clinic visits

I recently found out from our billing department that whenever we have a patient encounter that we’ve billed as both a “well visit + an acute (or follow-up) visit” using a modifier 25 (assuming it meets the criteria of both), that the reimbursement ends up amounting to approximately:
            the entire “well visit” reimbursement + ~50% of what would have been the “acute or follow-up“ visit (regardless of level coded)

That is in contrast to receiving the full reimbursement if we have the patient/family come back for a separate visit to take care of either component of the care (the well visit or the acute issue), rather than taking care of all of the things the day they are in clinic.  This is particularly challenging as we attempt to better address the needs of our adolescent population who we already know aren’t coming to clinic very often, so we are often trying to address multiple things simultaneously to make the most of every encounter.

I would be interested in hearing if others have OR have not found this same issue.  Do you see a difference in practice between your Medicaid versus Private insurers? Is there any other pattern you have noticed when you give this type of care & bill appropriately?

Thank you ahead of time for your input & time!

Michele Dritz, MD
Dayton, OH

--
Michele Dritz
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://lists.deltaforce.net/pipermail/ohioaap-practicemanagers/attachments/20170424/27b9c83e/attachment.html>