Wellness Visit Plus a Problem: Splitting the Encounter
A 70-year-old Medicare patient schedules her initial annual wellness visit (AWV). At the visit she also reports three weeks of right knee pain and swelling after a fall. The physician completes all AWV elements, then takes a problem-focused history, examines the knee, orders radiographs performed in the office, and prescribes naproxen. The AWV is documented on the wellness template; the knee evaluation is documented in a separate paragraph with its own history, exam findings, and decision making. Twenty minutes after the patient leaves, the physician calls her to explain the x-ray findings (mild osteoarthritis) and confirm the plan. The practice intends to bill the AWV, a 99213 with modifier 25, the radiographs, and a separate 99213 for the phone call.
1. Which of the four intended charges are billable, and what justifies the modifier 25?
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Billable:
- The AWV (initial AWV code). All required elements are documented on the template.
- The problem-oriented E/M with modifier 25. The knee complaint is a significant, separately identifiable problem with its own history, exam, and decision making, documented separately from the wellness content. That is precisely what modifier 25 attests to: the E/M was above and beyond the preventive service and not a re-counting of its elements.
- The radiographs, reported with the appropriate unilateral knee radiography code for the views obtained.
Not billable: the 99213 for the phone call.
Why the split survives scrutiny here: the two services drew on different documentation. The AWV elements are on the template; the knee history, exam, and plan are in their own paragraph. No element was counted twice. Had the knee work been folded into the wellness template fields, modifier 25 would have no support.
Patient financial responsibility: the AWV itself carries no coinsurance or deductible, but the problem-oriented E/M and the radiographs do. The patient should have been told that a separate, cost-sharing service was being provided.
2. Why is the phone call not separately billable?
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Because it is inside work already paid for, and because it does not stand alone as a billable service.
Two independent reasons:
- It is part of the E/M already reported. Ordering the radiograph, receiving the result, and communicating the interpretation and plan is follow-up to the encounter just billed. Reporting a second E/M for the same problem on the same day is duplicate billing for one episode of care.
- It does not meet E/M criteria. A brief results conversation - no new history, no examination, no new medical decision making beyond confirming a plan already made - has no separately documented history, exam, and MDM to support a 99213. Telephone E/M codes require a medical discussion of a sort that this call does not represent, and they are not a mechanism for billing brief result callbacks.
Rules vary by payer and by year for telehealth and telephone services, so the practice should verify current coverage policy - but no policy converts a two-minute result explanation into a 99213. The correct answer is to bill nothing for the call, and to keep the documentation of the call in the record as part of the episode.
3. Suppose the knee evaluation had been squeezed into the wellness template with the only entry reading 'knee pain, naproxen, x-ray ordered.' Could you bill modifier 25?
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No.
The problem is evidentiary, not stylistic. Modifier 25 tells the payer that a significant, separately identifiable E/M occurred alongside the preventive service. The documentation has to be able to show it: a history, an examination, and decision making that are distinguishable from the wellness elements and not double-counted.
A one-line entry gives you nothing to distinguish. There is no history of the fall, no exam findings, and no reasoning about the x-ray or the medication choice. Billing the E/M with modifier 25 on that record invites a denial on review and, if it is a pattern rather than a one-off, an overpayment finding.
What you can and cannot do:
- Can: query the physician - did a separately identifiable evaluation occur, and can it be documented? A late addendum that accurately reflects what happened is acceptable if your facility's policy permits it and the physician authors it.
- Cannot: reconstruct the note from the order and the prescription, or bill the E/M on the assumption that the work must have happened because the x-ray was ordered.
- If no separate documentation is produced: bill the AWV only. The knee discussion is part of the wellness encounter, unbillable separately, and the practice absorbs the work - which is the correct outcome when the record does not support the charge.