annual physical, insurance, insurance insanity, medicine, primary care, wellness exam

Physicals, Billing and Insurance: Coding 101

The “annual physical exam” is somewhat sacrosanct. It’s also a bit contentious. Often doctors and patients swear by its importance, while lots of research shows that the annual physical does not really show any evidence of contributing to better health.

I’m not going to talk about the values of the annual physical today- that would be a post for another day. What I am going to talk about is how we charge for an annual physical and how an insurance company pays for it.

First off- it is imperative to understand a bit about how we charge for medical visits.  We do this by a process called coding.  Every diagnosis under the sun is assigned a “code.”  There are literally tens of thousands of codes.  The code for an annual physical is V70.0.  Every time I see someone in the office, I have to write down the codes for all of the diagnoses that I am dealing with at that visit.   Then, based on the complexity of the visit, I assign an “evaluation and management code” to the visit.  This basically grades the complexity of the visit on a scale of 1 to 5, with 5 being the most complex.  How I reach that number is totally complicated and nuts, but again, that’s a post for another day.

Physicals are billed using a V code.  V codes signify that medical care is taking place that does not involve an E&M level.  Preventative care, such as the annual physical, falls into this category.

What does all of this blather mean?  It means that an annual physical is purely a “wellness” visit.  Coding guidelines specifically state that there are “no complaints” for an annual physical, meaning that the patient is healthy and only preventative care is being discussed.

Why is this important?  Most insurance companies, and Medicare, pay for an annual wellness physical with no copay and no out-of-pocket expenses.  There is no deductible for most plans.  However, the only thing covered is the wellness exam.  Technically, if you have an acute complaint the day of a physical, one of two things should happen.  Option one- the appointment is no longer a physical and should be charged as a regular office visit and assigned an E&M level.  Option two- the appointment is still a physical and is charged as a physical with what is called a modifier code.  A modifier code allows both a physical and an acute office visit to be charged at the same time.  With either option one or two, you are going to have your regular copay and deductible apply, because it is no longer just a routine physical.

I don’t usually take option two.  If someones acute complaints are severe enough for me to consider either of these options, I take option one.  The visit becomes a regular office visit, and we re-schedule the annual physical to another day.

Here’s an example.  Let’s say someone schedules an annual physical with me.  While reviewing their general health, I find out that they’ve had uncontrolled thirst and urination for a month.  I check their blood sugar and it’s 300.  They have new-onset diabetes.  At this point, this is no longer a routine wellness visit.  I need to get lab work, start medications, and educate the patient regarding diabetes.  This needs the patient’s full attention, and mine, and it deserves a visit all of its own.

Here’s another example.  A patient comes in for an annual physical.  She is visibly anxious.  She just found a breast lump and is very concerned because her mother died of breast cancer.  Again, this is no longer a routine annual physical.  It is now an acute visit for a breast lump.  The patient needs some tests, possibly a referral to a surgeon, and counseling.

Get it? Here’s the crux of the matter.  Just because you want a physical doesn’t mean you’re going to get one.  Just because you booked a physical doesn’t mean you’re going to get one.  What you are going to get is appropriate medical care.  The rest is just semantics.  However, if you get appropriate medical care that is NOT a routine physical, chances are your insurance company is going to want you to pay your copay and deductible.

And that’s not my fault.  I don’t make these Byzantine rules, but I do need to follow them.  My job is to provide the correct medical care.  My contract with your insurance company requires me to bill them appropriately.  So, DO NOT ask me to bill an acute visit as a routine physical so that your insurance will cover it.  That’s called fraud.  And I won’t do it.  Period.  End of discussion.  Even if you’re my favoritest patient in the whole wide world.  No matter how much I love you, I won’t commit fraud and risk prison time for you.  Sorry.

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