To anyone that understands coding in the medical field

SeaMaiden · ‎03-10-2010

If I am scheduling for a yearly insurance preventive exam... what do I ask for to make sure it is coded as the free yearly exam? Thank you!

Nightowlz · ‎03-11-2010

I would also like to know. Guess your Ins. Co can tell you. Mine has only coded 1 appt as such where I did not have to pay. All other appts I had to pay. I also think if you start asking more questions it goes on to more then the "wellness appt". My doctor should always charge as the wellness appt because I don't pay anything & he gets paid more from ins when he does??? I only go once per year to see him so IMO mine should be that yearly wellness appt. I had to go 3 times this year since I had Shingles but I normally only see the doctor once per year.

Mom2Dogs · ‎03-09-2010

@SeaMaiden, when I scheduled for preventive tests, I made it clear when the appointment was made that is was preventive....I also mentioned it again when I checked in. I never had an issue but dh did when he went for a test that should have been covered 100%, I made the appointment so I know I was clear when I called but we were billed for the test!

DH called and let them know, they resubmitted the paperwork and the cost was removed.....just be sure to read your bill very closely, I have found several mistakes (double billed) in the last few years.

HerRoyaLioness · ‎03-13-2010

I hesitate to post on this, but I used to code them. It's all in the wording, the language, so you are right to make sure you have it correct.

It matters what insurance you have. If you are talking about Medicare, it's usually a problem. A yearly or annual physical is not a covered benefit by regular Medicare. Every 2 years they will pay for a breast, Pap and pelvic (only) exam. Otherwise they do not pay for a yearly preventive exam. You need to really check your policy closely for what preventive services are covered and how often.

(If you have a Medicare HMO, like I do, they will pay for a yearly exam.)

A Wellness visit is totally different and I would go online and see what it covers, usually no physical exam. You can call Medicare, but even they don't give out accurate information sometimes. You can have a wellness visit and if you have a problem they can also charge an office visit with the "Wellness" visit.

It is important when you get there that you tell the nurse what you are there for - she is the one who will put that reason in the record. When the dr comes in he will refer to that for what he/she needs to do.

We used to have patients who thought the wellness visit was a complete yearly exam - it is not. I know this is confusing! But if you truly just want a yearly physical exam, be prepared to pay something. We used to "carve out" the costs for the physical exam from the breast, Pap and pelvic (paid for) part so it was fair to the patient.

If you have a medical issue, it would be just an office visit and you usually would get some sort of exam. And be aware that if you have a supplemental insurance, they usually will not pay anything for a non-covered service. If Medicare won't pay for it, they won't pay for it.

Hope this helps and remember the rules are constantly changing, so check with your insurance or talk with the billing at your clinic. They are usually well informed on what is covered.

SeaMaiden · ‎03-10-2010

@Mom2Dogs wrote:
@SeaMaiden, when I scheduled for preventive tests, I made it clear when the appointment was made that is was preventive....I also mentioned it again when I checked in. I never had an issue but dh did when he went for a test that should have been covered 100%, I made the appointment so I know I was clear when I called but we were billed for the test!

DH called and let them know, they resubmitted the paperwork and the cost was removed.....just be sure to read your bill very closely, I have found several mistakes (double billed) in the last few years.

@Mom2Dogs Thank you for your post! My husband tends to be very lax about things. I try to tell him that it is important to clarify what the appointment is for before and when at the appointment. But....MEN! Must I say more.... I thought if I had the code for the preventative physical we could just tell them that so they would code it right. I am thinking it is a universal coding system?

HerRoyaLioness · ‎03-13-2010

@SeaMaiden wrote:
@Mom2Dogs wrote:
@SeaMaiden, when I scheduled for preventive tests, I made it clear when the appointment was made that is was preventive....I also mentioned it again when I checked in. I never had an issue but dh did when he went for a test that should have been covered 100%, I made the appointment so I know I was clear when I called but we were billed for the test!

DH called and let them know, they resubmitted the paperwork and the cost was removed.....just be sure to read your bill very closely, I have found several mistakes (double billed) in the last few years.
@Mom2Dogs Thank you for your post! My husband tends to be very lax about things. I try to tell him that it is important to clarify what the appointment is for before and when at the appointment. But....MEN! Must I say more.... I thought if I had the code for the preventative physical we could just tell them that so they would code it right. I am thinking it is a universal coding system?

It is a universal coding system, but we have to code according to what the dr actually does at the visit, not what the patient might tell us to code to get the charge paid. That would be fraud. Correct coding is what was done at the visit and why it was done. The procedural code and the diagnosis code would be determined by what the visit was for.

Hayfield · ‎03-10-2010

The best bet is to know what your insurance pays for and how often. If you can't find it on their website, call them up and ask them. That's what I do if I don't understand something and I do it before I go to the doctors if I have a question about something. For example I wanted to get the shingle shot and not have to pay for it, I called and talked to my insurance company and they told me that at the age of 60, they pay for it. If I wanted to get it before the age of 60, then I'd have to pay for it. I waited until I was 60 to get it but I do have a friend that got a case of shingles at 54 and the AMA suggests getting the Shingle Shot at 50 but it'swhat your insurance says that counts.

CatLoverDogsToo · ‎03-10-2010

@HerRoyaLioness You definitely know what you are talking about. I dealt with insurance companies for over 10 years.

You said: "You can call Medicare, but even they don't give out accurate information sometimes."

Absolutely correct, and if they give wrong information, there is no recourse, they are not liable at all.

Reading the rules and regulations for medicare were a nightmare and in many cases contradictory.

I have no idea if it has gotten better or worse. I left the "business" many years ago.

“The price of light is less than the cost of darkness.”
– Arthur C. Nielsen

SilleeMee · ‎05-22-2016

I ask for a "wellness exam" and make sure that when I make the appointment that the person making my appointment has it down to comply with the once-yearly ACA rule. I'm not on Medicare but private insurance.

Some places call it a "wellness visit". @SeaMaiden

chrystaltree · ‎05-10-2010

@HerRoyaLioness wrote:
@SeaMaiden wrote:
@Mom2Dogs wrote:
@SeaMaiden, when I scheduled for preventive tests, I made it clear when the appointment was made that is was preventive....I also mentioned it again when I checked in. I never had an issue but dh did when he went for a test that should have been covered 100%, I made the appointment so I know I was clear when I called but we were billed for the test!

DH called and let them know, they resubmitted the paperwork and the cost was removed.....just be sure to read your bill very closely, I have found several mistakes (double billed) in the last few years.
@Mom2Dogs Thank you for your post! My husband tends to be very lax about things. I try to tell him that it is important to clarify what the appointment is for before and when at the appointment. But....MEN! Must I say more.... I thought if I had the code for the preventative physical we could just tell them that so they would code it right. I am thinking it is a universal coding system?
It is a universal coding system, but we have to code according to what the dr actually does at the visit, not what the patient might tell us to code to get the charge paid. That would be fraud. Correct coding is what was done at the visit and why it was done. The procedural code and the diagnosis code would be determined by what the visit was for.

I'm glad you weighed in on that. This is something that patients aren't involved in, coding the way a patient wants things coded, is major fraud. We code based on clinical documentation and only on that.