quote:
So what do you think crosses the line from annual wellness visit to cha-ching cha-ching? Specific examples, please. How many issues? Assume it's all done in one visit in the allotted time.

I'm asking because every time I go for my "annual wellness visit," I'm told at the desk it's free, but then if I comment on anything, no matter how minor, my doctor codes it differently, I get charged for it, and I have to spend 30 minutes on the phone getting it fixed. I've gotten it fixed every time, but I'm sick of this shite. I'm looking for a new doctor because of it.

Preface: coding and billing is a topic that can be discussed for hours and nuances exist all over the place.

So, it isn't about "cha ching," so much as it is what is going to be scrutinized by the insurance company. A wellness visit means "I have these old problems that you know about and treat me for but am doing fine" or "sometimes I can't sleep when I drink coffee after 5pm" or the like.

When you come with a new problem, such as knee pain, however innocuous it may seem, the insurance company no longer considers that "wellness." They consider it a "problem." I and my practice (still in residency, but we run a private clinic and have a majority of privately insured patients + medicare with a decent Medicaid population, too) will usually just ignore problem codes and bill wellness even if we change a few minor things. They pay us differently because of this.

What they require from every visit is a few things. 1) the level of care (wellness code, problem (complexity) code, or procedure code). Each of these is very different to the insurer. What they also have is a list of problems (icd 10 codes, essentially a 1-10 word summary of the visit boiled down to a generic code like "left hand pain" or "well adult exam" or "osteoarthritis of right knee" or "laceration of face." Each insurance only will allow the charge (wellness, procedure, or problem) based on the icd10 code. This means that when you talk about knee pain at a wellness visit and the doc puts the icd10 code for knee pain in (as they want you to do for accuracy) as well as the one for wellness, they will frequently (depending on the insurance company) reject the "wellness" charge and will not reimburse the visit. Some allow you to bill the wellness + problems. Some allow you to code the wellness + problems. There is no consistency here, unfortunately- it varies by insurance.

So the docs essentially do nothing different for the visit, but when it comes to coding/billing, it requires some judgment and development of a practice pattern. Some lose out on money they could have billed for looking at a new bump on the skin. Some code and bill for all they can because the rules not only say they can, they say they should.