Getting paid for prevention: Physicians facing coding challenges

Promises of payment for managing chronic illness and preventing disease have doctors struggling to track and bill for both "well" and "sick" care.

By Emily Berry, AMNews staff. March 24/31, 2008.

Health insurers are offering incentives to persuade members to see doctors regularly for "well visits" and to manage chronic illnesses. Physicians know that treating an acute problem pays better and is easier to bill than prevention.

Consultants and physicians say learning how to code, bill and schedule around prevention can bolster patient care and fair payments. But doctors often struggle with insurers to ensure that coding will be recognized and that they are paid fairly.

The difficulty in documenting and billing for preventive care and sick care is encapsulated in a common situation: A patient comes in for a checkup then mentions a symptom -- shortness of breath, chest pain -- that merits its own conversation and examination. Or, conversely, the patient comes for a specific treatment, but then wants to discuss how to stop smoking or how to avoid the heart disease that runs in her family.

"It's always a challenge when doing preventive care and disease care during the same visit," said Tom Weida, MD, medical director for Penn State Milton S. Hershey Medical Center's family practice in Hershey, Pa. Doing both kinds of medicine provides an opportunity, but also a trap. If you can get reimbursed only for a sick visit or an annual exam, which do you do, and which do you bill for?

"It's so hard to do the differentiation. ... We bill for pretty much what they came in for and gift the other things," Dr. Weida said.

To help physicians parse what specific type of care they give, the Current Procedural Terminology manual includes detailed guidance about preventive visits, screenings and disease management. But often the line between sick and well care is fuzzy, leaving doctors or staffs to decide how to bill.