Successfully Bill a Preventive Service with a Sick Visit
Documentation is the key to avoiding billing issues.
By Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC
There are two types of office encounters: preventive and problem-oriented. Billing either type of visit alone is relatively straightforward, but when billing both visit types during the same encounter, documentation and billing issues can occur. We’ll focus on the Centers for Medicare & Medicaid Services (CMS) and CPT® rules that govern this unique billing situation.
Distinguish Preventive Services
Preventive medicine evaluation and management (E/M) visits, or annual exams, are comprehensive exams for the sole purpose of preventive care (i.e., to promote wellness and disease prevention). These services are represented by CPT® 99381-99397. The codes are age-based, and distinguish between new and established patients:
99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
99382 early childhood (age 1 through 4 years)
99383 late childhood (age 5 through 11 years)
99384 adolescent (age 12 through 17 years)
99385 18-39 years
99386 40-64 years
99387 65 years and older
99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
99392 early childhood (age 1 through 4 years)
99393 late childhood (age 5 through 11 years)
99394 adolescent (age 12 through 17 years)
99395 18-39 years
99396 40-64 years
99397 65 years and older
Do not confuse the term “comprehensive,” used in the context of defining a preventive service, with the definition of “comprehensive” as used in the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services. CPT® stresses, “The ‘comprehensive’ nature of Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the ‘comprehensive’ examination required in Evaluation and Management codes 99201-99215.” The extent of examination and anticipatory guidance associated with a preventive service is based upon the provider’s judgment.
Medical Necessity Should Determine Services and Coding
During a preventive exam, patients often say, “Oh, by the way …,” which will prompt an additional, problem-oriented service. Several variables influence how you report a combination preventive/problem-oriented encounter. Billing largely depends on the payer, and sometimes on contractual agreements, as well as provider documentation.
The key is to document what you medically need to do and bill for what you document. In fact, this statement is my personal motto: Document what you do and bill for what you document.
CPT® instructs, “If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management 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.”
There will likely be ‘work’ done for the problem-oriented service that would have been performed during the course of a routine preventive service. In other words, there will be an overlap of work. If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work should not be used to calculate the additional level of E/M service. When selecting the additional E/M level of service, only the work that was performed “above and beyond” what would have been performed during the preventive service should be used to calculate the additional E/M level.
Documentation needs to support billing both services. The provider may elect to create two separate notes to support the two separate services. This may be the best practice, but it also creates more work for a provider. If the provider creates one document for both services, he or she must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. For example:
- The key elements supporting the additional E/M service must be apparent to an outside reader.
- A separate history of present illness (HPI) paragraph describing the chronic/acute condition supports additional work needed in the history (there shouldn’t be an HPI in a preventive service).
- The provider should clearly list in the assessment the acute/chronic conditions that are being managed at the time of the encounter. If there is a portion of the exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., “A thorough MS and neuro exam of the left hip performed as it relates to the HPI”).
Consider Your Payer when Billing
When billing a commercial payer, a preventive service and additional problem-oriented E/M service are billed on the same claim form and at the full fee schedule. Some clinics may elect to reduce the fee for the additional E/M service when performed at an annual exam as a customer service benefit.
When billing Medicare, the additional E/M service must be “carved out” from the preventive service. That is, any part of the history, physical exam, or plan portion of the annual exam performed to address a chronic or new issue can be separated from the non-covered preventive exam. This carved out portion of the service may be submitted to Medicare for coverage. In this case, the overlap of work can be used to calculate the additional level of service. Only those elements in the history, exam, and plan that directly address the chronic illness or new problem may be used to determine the appropriate level of E/M.
Whether you are billing to a commercial payer or to Medicare, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the additional E/M code. Modifier 25 is appended to indicate that ‘the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided.
Billing Medicare Patients for the Preventive Portion of the Service
When billing a preventive visit with carve outs, a Medicare beneficiary may be billed for the difference between the standard fee for the preventive service and the amount that Medicare will cover. In such a case, you would not receive the full, regular payment for the preventive services.
For example, at a preventive visit, an established patient mentions a lump she has noticed developing in her breast. The physician does a separate workup for this problem and performs a breast screening:
99397 est. patient preventive visit standard fee = $100
99213-25 est. patient, office “sick” visit = $30
G0101 cervical CA screening w/breast and pelvic exam = $30
Let’s say your usual fee for the preventive visit is $100, while the sick visit and screening are billed at $30 each. You may bill the patient only for the difference between the cost of the covered and non-covered services.
$100 (not covered by Medicare)
– $30 (covered by Medicare)
$40 is the patient responsibility
Medicare does cover some screening (preventive) services. For example, for the female patient, a screening pelvic examination and/or Pap is a covered service. The full policy may be found on the CMS website.
For the male patient, a screening prostate exam is a covered service and would need to be carved out from a preventive service. The full policy may be found on the CMS website.
Prep Patients for Billing Issues
Patients may not understand there is a difference between preventive care services and problem-oriented services, or may not understand the billing and coding is also different. It may be confusing for the patient to see two bills for one office visit, which could spur patient complaints. Educating patients prior may help to alleviate some of their confusion.
It is also important to be consistent with billing practices, especially in a group practice. Inconsistent billing among providers within a group practice could create variations in the bill that the patient receives from year to year, and this could also cause confusion and complaints.
Meet Minimum Requirements for Medicare Screening Pelvic Exam
When billing a covered screening pelvic examination for a Medicare beneficiary, the documentation needs to include at least seven of the following elements:
- Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge; and
- Digital rectal examination for sphincter tone, presence of hemorrhoids, and rectal masses.
- Pelvic examination (with or without specimen collection for smears and cultures) including:
- External genitalia (general appearance, hair distribution, or lesions)
- Urethral meatus (size, location, lesions, or prolapse)
- Urethra (masses, tenderness, or scarring)
- Bladder (fullness, masses, or tenderness)
- Vagina (general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, or rectocele)
- Cervix (general appearance, discharge, or lesions)
- Uterus (size, contour, position, mobility, tenderness, consistency, descent, or support)
- Adnexa/parametria (masses, tenderness, organomegaly, or nodularity)
- Anus and perineum
Coverage for the screening pelvic or prostate examination are provided as a Medicare Part B benefit. When performing a combination of a preventive exam, a covered exam and, for example, Q0091/G0101 or G0102, the provider must carve out the covered services from the amount he or she bills the beneficiary.