Billing & Coding 101 
For Primary Care

STEP 1. DETERMINE IF NEW OR ESTABLISHED PATIENT

       Encounter --> Primary care visits only ; determine if you see an associate from same group within 3 years 

             (Adult med, IM, Ped, Skilled Nursing, Urgent care, FM, IMPED, Hospitalists, Transitional care, SC IMR*)

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STEP 2.  ANNUAL PREVENTATIVE VISITS?

 PART A) Determine level of Service: IPPE vs AWV vs ACP vs PEX vs ACV vs exta (EM)​

      IPPE = welcome to medicare (physical exam included) *if only within 1 year of signing up to Medicare​

      AWV - Annual wellness visit (No physical exam)  ​

                        G0438 = initial first ever AWV ​

                        G0439 = subsequeent visit ​

      ACP- advanced care planning (spend at least 16 min planning, less is not billable) ​

​               -AWV ? add modifer 33 

               - ACV? add modifer 25 and 33 for the acp code​

               -99497 is for 16 to 30 minutes​

      PEX is Physical Exam (Medicare does not pay for them) ​

              - New patient    99385 = 18 to 35 yrs    ; 99386 = 40 - 64 yr olds    ;  99387 for +65 yr old​

​              - Established Pts  99395 = 18 - 35 yr olds  ; 99396 = 40 - 64 yr olds   ;  99397 for +65 yr olds 

     ACV - annual comprehensive vist only to medicare advantages its combination of ...​

                  AWV (G0438/G0439) + Physical Exam (993xx) 

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      Problem EM is when you are billing for seperate pertinent issue apart from the Annual wellness visit

                    add modifier 25. ​

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​         Diagnosis Code (Z code) for IPPE, AWV, PEX, ACV =

                    Z00.00 (wellness w/ nml findings)

                    Z00.001 (wellness with abnml findings must be documented) ​

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STEP 3. Medical Decision Making "MDM" =  (problem addressed) +  ( data analyzed) +  ( risk management )               

               you must meet 2 / 3 of them

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Screening Z codes ​

lipid panel, TSH, BMP, HgbA1C, CBC with differentials

instead of using "screening for" x y z disorders 

use : Hyperglycemia, hypothyroidism, hypercholesterolemia, Anemia (unspecified type) = increases likelihood of getting accepted by insurance helps you and your patients pay less.

 

PCE primary care exceptions are those kind of conditions that allow residents to see patients without attending seeing the PTs.​

Level 2 and 3 (99202 99203 99212 99213)  = see independently by resident

All PEX (physical exam) + ACV + AWV requires attending to see the patient or it wont be billable. 

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MODIFIERS​

GE = "service provided by Resident independently" = Apply this to 99202 99212 99203 99213 

GC = "Service provided under direction of attending physician" = apply service that falls outside of PCE

25 = "significant seperately identified problem on same day visit 

                - E/M "Stand alone service 

                - add 25 to existing E/M service documentation should support this 

 GT = Video Zoom (GT to and E/M service please) 

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