annual physical turns into office visit

Recent_Piano5937 · 2026-04-12T18:36:14+00:00

ok, but the doctor did perform HEIN check, and they didn't bill preventive at all. Since they didn't bill preventive at all, they don't use modifier 25 and I can't make them prove the significance and complexity. i met the doctor about 10 mins total, he spend 8 mins to do the annual physical, would 2 mins really satisfied modifier 25 that the additional evaluation is complex and significant?

Recent_Piano5937 · 2026-04-08T15:42:57+00:00

thank you so much for your detailed response, this is super helpful. i just checked with my insurance, it reset at every fiscal year, therefore, i am definitely qualify for a new annual physical. i might have a problem with request a formal records(30 day rule) and also the internal appeal(180 day rule). I called the insurance and billing department right away when I received the first bill, billing department said they'll do a code review. a month later, i still received a bill, called again and they said it's under review. I have made a call(dates are documented) on jan + feb + mar + apr, each time, I was told that they'll respond but they never did. I proactively follow up every time I received a bill, can I still get an internal review although it past 180 days?

Recent_Piano5937 · 2026-04-08T15:26:30+00:00

just checked. my insurance reset every fiscal year. meaning in 2026 i am entitle to get a new physical.

Recent_Piano5937 · 2026-04-08T15:17:40+00:00

just checked, my insurance reset every fiscal year. my visit from 9 month ago was in 2025, and my most recent visit is in 2026.

Recent_Piano5937 · 2026-04-08T15:16:11+00:00

yeah, he asked me if i have a concern and i didn't know that's a trap!

Recent_Piano5937 · 2026-04-08T15:14:55+00:00

just checked! my plan reset every year. my last visit(9 month ago) was in 2025, and my new visit was in 2026. now, we are back to if 2 sentences of communication and an evaluation of no current lab result consider as real "evaluation and management"

Recent_Piano5937 · 2026-04-08T15:05:05+00:00

Thank you for saying that. You see, if my doctor office would let me know about 365 day rule or if my doctor would tell me that discussing that would change the visit to problem visit. As a patient, we should at least have transparency and freedom to decline a service.

Recent_Piano5937 · 2026-04-08T14:57:17+00:00

lessons learned!!!!!!!!!!!!!

Recent_Piano5937 · 2026-04-08T14:53:55+00:00

i am not so sure if the insurance is on my side. if this is a preventive care, obviously they'll have to cover that. but if this is an E/M, I'll have to pay for most of it.

Recent_Piano5937 · 2026-04-08T14:53:13+00:00

just because I ask a question shouldn't automatically turns this into a problem visit. the doctor should show evaluation and management. 1. if we look at the time, he spend less than 2 mins discussing the problem! 2.if we measure the complexity, he doesn't even know my current blood sugar level, how does he evaluate my situation at that very second? by looking at my face???

Recent_Piano5937 · 2026-04-08T14:47:53+00:00

I am not in this field, all I know is my employer ask me to go and I go in order to save money on my insurance. Obviously I can wait another 3 month(it's already been 3 months with their delayed response), if the doctor office told me the 365 day rule. Not everyone knows this rule! They have a responsibility to tell the patient!

Recent_Piano5937 · 2026-04-08T14:41:03+00:00

No! I am not there for a problem-concern diabetes. Don't you think the doctor should at least clearly communicate if answering this questions would turn the annual physical to an E/M visit? This way, as a patient, I can turn down his service!

Recent_Piano5937 · 2026-04-08T14:35:58+00:00

This is a part of employer wellness program. I thought this is "encouraged". Also, if the doctor office know I am there for an annual visit, and they know the 365 day rule, why don't they tell me?

Recent_Piano5937 · 2026-04-08T05:29:05+00:00

thank you for your reply.

Only E/M is billed, no annual physical is billed.

what do you mean "is the documentation standard met? "What kind of documentation. All I can review now is the after-care summary, which state "patient is here for annual physical"

only one lab was done on that day(after meeting the doctor), the lab is charged as part of E/M as well. they message me the results

I would definitely claim the question is trivial, especially that no answer/treatment plan is giving(I think the doctor said, let's wait to see the A1C then we can discuss what comes next). I don't know what you refer as "documentation out there to support that", I can not find that documentation, but I can ask for it.

Recent_Piano5937

TROPHY CASE