Preventative Medicine vs. Evaluation and Management Codes

Choosing a proper office visit code can become confusing unless one understands the rules separating preventative medicine and evaluation and management coding.

Preventative medicine codes are meant only for the reporting of asymptomatic patients. In order to assign a preventative code, a comprehensive evaluation must be documented. The scope of a preventative visit depends both on the patient’s age and screening test(s) fitting the age of the patient.

Medicare does not cover the CPT codes 99381-99397 (preventative medicine services). When billing a preventative medicine visit for a Medicare patient, a waiver of liability is NOT required. This is based on the Social Security Act, Section 1862(a)(7), Statutory Exclusion. The patient is responsible for 100% of the accumulated debt in such instances. The amount that other commercial insurance carriers will pay depends on whether these services are included in the individual’s insurance plan.

Coding Guidelines for CPT Preventive Medicine Services

In CPT, codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients. Preventive medicine services are represented in evaluation and management (E/M) codes section of CPT. These E/M codes may be reported by any qualified physician or other qualified healthcare professional, i.e. NP, APP or PA.

Components of a Preventive Medicine Visit:

Preventive visits, like many procedural services, are bundled services. Unlike documenting problem-oriented E/M office visits (99201–99215), which involves complicated coding guidelines, documenting preventive visits is more straightforward. The following components are needed:

• A comprehensive history and physical exam findings;
• A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT;
• Notes concerning the management of minor problems that do not require additional work;
• Notes concerning age-appropriate counseling, screening labs, and tests;
• Orders for vaccines appropriate for age and risk factors.

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. Rather, it requires a “comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.” The preventive comprehensive exam differs from a problem-oriented comprehensive exam because its components are based on age and risk factors rather than a presenting problem.

Coverage of preventive visits varies by insurer, so it is important to be aware of the patient’s health plan. Most plans limit the frequency of the preventive visit to once a year, and not all tests are covered. Fecal occult blood tests, audiometry, Pap smear collection, and vaccines and their administration should be billed separately. Visual acuity testing is not separately reimbursed.

Without a new or chronic-disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-10-CM code for screening should be assigned on the order form and claim.

When billing for a preventative medicine visit, it is legal to also bill for an evaluation and management service if a patient wants a medical problem addressed at the time of their yearly physical exam. What you have to be careful of is a patient who presents with well-controlled chronic conditions with no complaints and is there to “establish care”. That may be considered a preventative visit to Medicare and Commercial plans.

The following is an example of when to consider billing a separate Evaluation and Management visit code in addition to a Preventative Medicine visit service:

An internal medicine physician sees an established patient Medicare aged patient for their scheduled yearly exam (preventative medicine). The patient did not mention any complaints when the appointment was made and stated that he wanted to be seen for an annual physical only. However, during the course of the visit, the physician determines that the patient has an enlarged prostate. This finding requires an evaluation and work-up that is separate from a preventative history and physical service.

If the internist finds a problem while performing an annual physical, and if the problem is “significant enough” to warrant additional testing, prescribing, or problem-work up, then the appropriate office visit code 99212-99215 should also be reported with a 25 modifier, to reflect the “significant separately identifiable service”. The services should be coded as 99397 (preventative established patient over 65 years old) and 99212-99215-25 for the evaluation and discussion of the enlarged prostate, depending on the documentation level of the E/M visit.

Plenty of practice managers have been faced with the question of whether to bill for a preventative medicine visit or an E&M level of service. The answer is relatively simple, bill according to the “intent” of the visit. If the objective is to provide an annual asymptomatic physical, then a preventative medicine code should be reported. Some sources state that you may bill a preventative medicine visit with a chronic condition such as hypertension or diabetes. If a physician is only managing a patient’s medication, there are no changes or concerns, and the patient then it would be appropriate to bill for preventative medicine. However, if a physician needs to make changes to that medication after finding out that it is causing side effects, utilize a proper evaluation and management visit code.

This is controversial, as the guidelines for the preventative services, in CPT references a subsection that states, “If an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine E/M service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.”

CPT goes on to say:

“An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E/M and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.” 

Only the physician can determine if the abnormality is “significant” enough to warrant two E/M services, and many times, there is a double co-pay for commercial plans and a higher out of pocket for Medicare patients. It may be a better idea to pick either a problem-oriented E/M visit over the preventative medicine visit and save that for another day. Again, it is a physician’s judgement, based on the level of care that was administered that day.

I would not want to see the decision based on the patient’s potential out of pocket share of cost, but it is a factor, when you consider what the patient scheduled. You’ll find most patients expect a “free” visit when they schedule a “yearly exam”. It’s important to explain to the patient that two separate services are being performed so they may expect additional charges, but it saves them the inconvenience of a second visit to address them both now.

CPT Assistant weighed in on this topic in 2009, and gave 2 examples of a preventative visit, again that was age and gender appropriate:

• Preventative Service for a 33-year-old woman, may include a pap and pelvic, breast exam and BP check. Counseling may be diet, exercise, substance abuse and sexual activity.
• For a 13-year old girl, it may include a scoliosis screen, assessment of growth, development, behavior, immunizations. Anticipatory guidance, health habits, self-care, avoidance of substances, avoiding risks associated with sexual activity, and even wearing a seatbelt while in a care.

But when would it be appropriate here to bill for an office visit in addition to the preventative service?

Take example 1. During the female adult preventative exam, the physician identifies a palpable solitary lump in her right breast. The physician finds this “significant” enough to require additional work, and to perform the key components of a problem-oriented E/M service. So 99395 would be reported for the preventative visit, and 99213-25 would be reported for the visit related to the breast lump.

Now in saying this, there are “covered services” under the umbrella of “preventative” that do not include an actual comprehensive exam or comprehensive history, but more of a “review” or current inventory of the overall health of the patient. The IPPE (see chart below) has minimal exam elements to include:

• Height, weight, body mass index, and blood pressure ● Visual acuity screen ● Other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards

Also, know the difference in what you are reporting. For Medicare beneficiaries there are 3 options:

Source: CMS MLN Booklet ICN 006904 August 2018

For additional guidelines regarding preventative medicine and evaluation and management coding, please refer to the American Medical Association (AMA) or Centers for Medicare & Medicaid Services (CMS) website.

Other References:

http://img.medscape.com/article/748/528/Comparing.pdf

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/mps_qri_ippe001a.pdf