By: Bradley Hart, CPC, COBGC

Coders often have to answer difficult questions when reporting services. In most cases, they are not life or death issues (such as Hamlet, who said, "To be or not to be? That is the question!"). However, those in primary care and women's health must often make a challenging determination-is the service provided to the patient a preventive service or is it a problem-oriented encounter?

Attendees at AAPC's National Conference in Orlando had the opportunity to participate in a session on this topic, with a focus on the way in which coverage for preventive services has changed over the years. The Patient Protection and Affordable Care Act (PPACA) has accelerated the change in coverage and coders must be aware of the practical effect that these coverage changes may have in patient relationships.

The History of Preventive Coverage
When health insurance was first introduced, its purpose was to shelter covered individuals from the costs associated with treating injuries and illnesses. Preventive coverage was not a covered benefit under the overwhelming majority of insurance policies. However, in connection with the introduction of Health Maintenance Organizations (HMOs) in the 1980's and 1990's, payers began to offer preventive coverage as a benefit-often with a lower copayment than problem-oriented services. The theory behind offering this benefit was that the net cost of preventing injury and illness was significantly less than treating them after they occur.

Coverage for preventive care grew increasingly popular as its benefits became clear over the years. Copayments were frequently reduced to lower levels as an incentive for patients to receive preventive services. The place of preventive care has been firmly entrenched in the U.S. healthcare system with the implementation of the PPACA, which mandates that all health plans that fall under the jurisdiction of the law must offer specified preventive care services at no out-of-pocket cost to the patient.

The Challenge of Preventive Care, Patient Relations, and Coding
Naturally, when given a choice between receiving services that have out-of-pocket costs and those that do not, patients would prefer services that have no cost. In addition, patients do not always know the specific terms of their coverage, such as the definition of "preventive" or the frequency at which these services can be received. When these two issues are combined, patients will often desire that their services be characterized as "preventive," when, in fact, they are not.

This can become an issue when the purpose of the encounter is not explicitly clear. There are four broad categories of service:

• It is clearly and obviously 100% a preventive medicine service.
• There are elements of the service that are clearly preventive and other elements that are clearly problem-based.
• The visit was intended to be 100% preventive, but the clinician found an issue that requires immediate attention.
• It is clearly and obviously 100% a problem-based visit.

In the first and last scenarios, there is very little room for debate or confusion. However, if there is a preventive component during the same encounter in which there is a problem-oriented component, how should the visit be characterized and coded? And, how does one decide?

Case Studies in Preventive Care
CASE 1: Evelyn is 52 years old and is an established patient of Dr. Franklin, who presented for a routine gynecologic exam. She is experiencing some vaginal itch and irritation, especially on the right side of her vulva. Her LMP was 3 years ago. She is not on HT. She states that for the last 6 months she has had occasional bleeding requiring the use of 1-2 pads per day. The bleeding usually lasts 1-2 days. She has no pain or other associated symptoms.

Evelyn's medical record for this service was as follows:
History

• Medication: None
• ROS: Positive for tired and sluggish, frequent headaches. Remainder of ROS neg. See Gyn intake form.
• PMH: Last mammogram 1 year ago. No changes in medical/surgical history since last visit.
• SH: No change. Denies sexual problems
• FH: Breast CA and heart disease maternal grandmother. HTN mother and grandmother.

Physical Exam

• Constitutional: Ht. 5'8"; Wt. 138; B/P 120/82. Pt. is well nourished and well developed.
• Psychiatric: She is oriented X 3.
• Skin: Moist without lesions
• Neck: Thyroid neg. Neck supple without adenopathy
• Chest: Clear to auscultation
• Heart: RRR w/o M, G, R
• Breasts: Checked in all positions. No masses, lesions, or galactorrhea.
• Abdomen: Soft, non-tender. No hepatosplenomegaly. No hernia.
• Pelvic: External genitalia: Skene's, Bartholin's and urethra negative. There was mild irritation of vulva.
• Vagina: Normal appearance. No sign of infection or bleeding
• CX: Well epithelialized.
• Uterus: Anterior, normal size and shape
• Adnexa: Both left and right were negative.
• Rectal: Good tone. No hemorrhoids. Occult-neg.

Procedure note:
 EMB was performed without difficulty. The patient tolerated the procedure well.
Impression/Plan
 1. Normal well-woman exam. Pap performed. Will call with results.
 2. Minor vulvar irritation. Discussed personal hygiene.
 3. Postmenopausal bleeding- EMB performed. F/up visit scheduled for 10 days to discuss biopsy results and management options.
 4.  Discussed benefits of baseline bone density study. Will obtain today in office.

In this case, the appropriate CPT codes that should be billed are:

• 99395-25-Preventive Care, Established Patient 40-64 years old
• 58100-Endometrial Biopsy
• 77080-Dual Energy X-Ray Absorptiometry (DXA), Bone Density Study

It is not appropriate to bill an Evaluation and Management (E/M) service for either condition that was addressed during the encounter-vulvar irritation or vaginal bleeding. Separate billing is not indicated because there is no indication of history or examination related to these issues that is separate and distinct from the history and examination that was attributable to the preventive care service.

This is a particular challenge for providers that provide gynecologic services because so many of the "problems" that are addressed in connection with preventive care services are in the genitourinary system-the system that is the focus of the preventive care service. Providers must ensure that if preventive services are going to be billed with problem-oriented E/M services during the same encounter, the documentation reflects significant and separately identifiable services that are not duplicative.

CASE 2: Margaret, a 42 year old woman, presents for her preventive gynecological exam. However, as soon as Dr. Clark enters the room, Margaret tells her about a breast lump that she identified four days ago and also reports that she is having significant, debilitating pelvic pain. The symptoms do seem to be cyclical, but the pain interferes with her ability to work approximately 5 days per month.
Dr. Clark exams Margaret's breasts and identifies a mass in the right breast. Margaret has not had a baseline mammogram. In addition, Dr. Clark performed a transvaginal ultrasound, which revealed a very large cyst on the right ovary. She recommends that Margaret immediately receive additional radiologic tests to analyze the breast mass and schedules an appointment with a breast surgeon for further evaluation. She also discusses with Margaret, at length, the possible treatment options for the ovarian cyst.

In this case, it would be appropriate to report only an E/M service and not report a preventive care service. Margaret may have expected that she was going to receive her services at no cost, but the nature of the service provided was clearly focused on the problems with which Margaret presented. Therefore, she would be responsible for paying for any copayment and/or deductible associated with her plan.

Managing Patients and Their Requests
As more patients become aware of the benefits available under the PPACA, it is likely that more patients will desire that their services be characterized as preventive care, which reduces or eliminates their financial responsibility. The most common way in which this may present itself is the patient may "save" their "problems" for their preventive care visit and seek to have them treated at the same time.

To address this issue, coders and their providers should take the following steps:

1.  Clearly define policies that distinguish the line between preventive services and problem-oriented services.
2. Engage providers in discussions concerning the handling of the cases in which the line is not clear. Are providers willing to tell patients that they won't treat "problems" during preventive care services? Are they willing to treat the "problem" for free so that the patient will have no out-of-pocket cost?
3. Educate patients about the benefits available under the PPACA so that they clearly understand that which is covered and that which is not covered-before the service is rendered.

Valuable educational sessions like this one will be available at next year's AAPC National Conference in Nashville, from April 13-16, 2014.

Bradley Hart, CPC, COBGC, has over 20 years of experience in billing and coding, with 13 years in medical practice administration. Recently he has focused on teaching and writing as a faculty member with ACOG, and his book, Ethics in Medical Coding: Theory and Practice, was published in 2012.