The health plan two-step

Most folks have heard of the Texas two-step. The Texas two-step is danced with two quick steps and two slow steps. 

The health plan two-step is even simpler. It is one step forward and one step backward. The latest demonstration comes courtesy of Aetna. 

In February 2006, Aetna agreed to pay the full allowed amount for a standard evaluation and management (E/M) service (e.g., a problem-oriented office visit), when billed with modifier 25 and a preventive E/M service. In essence, Aetna agreed to pay the full allowed amount for both services. This was progressive compared to other payers, like CIGNA and UnitedHealthcare, who only pay the acute service at a rate of 50 percent when done at the same encounter as a preventive medicine visit. Of course, some payers completely bundle the acute visit into the preventive visit in that scenario, resulting in payment only for the preventive service.

Anyway, Aetna took the second step of the health plan two-step earlier this month. Effective Aug. 15, 2009, Aetna began applying concurrency rules when two E/M services are billed and allowed with modifier 25, meaning each additional service is paid at less than the full amount. Aetna considers the preventive medicine visit to be the primary service and payable at 100 percent of the allowed amount; it considers the eligible office, or problem-focused, E/M to be the secondary service payable at 50 percent of the allowed amount. Apparently, there are others, like Aetna, who also giveth and taketh away.

The only upside that I can find in this particular dance is that Aetna's policy is now consistent with others' policies, so you have one less exception to remember. On the other hand, as Ralph Waldo Emerson once observed, "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." I guess Aetna thinks a lot of it, too.

Posted at 11:07AM Aug 28, 2009 by Kent Moore  |  Comments[2]

Another urban myth about coding

Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved.  He asked me if this was true. 

As I have done with other callers asking the same question, I assured him that this was incorrect information.  Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter).  For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  In no case does CPT state that medical decision making, by itself, determines the level of E/M service. 

Medicare policy supports this interpretation.  Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.”  That content includes the history and examination. 

This particular urban coding myth grows out of confusion between medical decision making and medical necessity.  As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”  Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance.  In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service. 

So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.

Posted at 04:47PM Apr 27, 2009 by Kent Moore  |  Comments[0]