Take Four Steps Toward Preventive Medicine Coding Success

By Beverly Welshans, CPC, CPC-I, CPC-H, CCS-P

The same care your providers take when administering preventive care to assure all has been covered must be taken when coding those services, as well. It never hurts to follow four simple rules that prevent denials on your preventive care claims.

Rule 1: Diagnosis Must Match Reason for Visit

Always match preventive medicine codes with an appropriate diagnosis. This means report a V code—even for Medicare patients.

Evaluation and Management – CEMC

Remember: The ICD-9-CM diagnosis code always should identify correctly the chief reason for the visit. A preventive medicine service is not a problem-oriented visit, so don’t code it as one. Instead, use an ICD-9-CM code to support the services provided (e.g., V70.0 Routine general medical examination at a health care facility for adults, V72.31 Routine gynecological examination for gynecologic exams and V20.2 Routine infant or child health check for well-child care. Additional special screening codes (V73.0-V82.9) also may be used, as appropriate.

Rule 2: Follow “Three-Year Rule” for New vs. Established

CPT® includes two subsets of preventive medicine codes: 99381-99387 for new patients and 99391-99395 for established patients. The distinction between new and established follows the standard three-year rule. Specifically, if the patient has never been seen, or was not seen by you or anyone else in your group within the past three years, the patient is new. All other patients are established.

Tip: CPT® Evaluation and Management (E/M) Service Guidelines include a “Decision Tree for New vs. Established Patients” to help determine if a patient is reported as new or established.

The new and established patient codes are divided further by patient age:

  • Younger than 1 year: 99381 (new) and 99391 (established)
  •  1-4 years: 99382 (new) and 99392 (established)
  • 5-11 years: 99383 (new) and 99393 (established)
  • 12-17 years: 99384 (new) and 99394 (established)
  • 18-39 years: 99385 (new) and 99395 (established)
  • 40-64 years: 99386 (new) and 99396 (established)
  • 65 years and older: 99387 (new) and 99397 (established)

Rule 3: Patient Age and Gender Determine Preventive Service Content

Preventive medicine services always include a comprehensive history and examination, and age-appropriate anticipatory guidance. The comprehensive examination is not held to the rigid “two bullets from each of at least nine body systems” required in a standard 1997 Documentation Guidelines for Evaluation and Management Services multi-system exam; rather it reflects the required assessment based on the patient’s age and gender. The focus of services rendered to a one-year-old infant, for example, will differ from those provided to a 28-year-old woman.

Services for a young child assess physical growth (height, weight, head circumference) and development milestones (speech, crawling, and sleeping habits). Anticipatory guidance includes car seat use and other safety issues, introducing new foods, etc.

An adolescent preventive service may include a scoliosis screen, growth and development assessment, and immunization review. Anticipatory guidance will focus on developing good health habits and self-care, including possibly a discussion of drugs, alcohol, and tobacco; sexual activity; and other peer pressure issues. Educational activities and social interaction are discussed and encouraged.

In the adult population, the same principles apply. A comprehensive preventive visit for a female patient includes a gynecologic examination, Pap smear, and breast exam. An adult male’s exam includes an examination of the scrotum, testes, penis, and the prostate for older patients. (It is not appropriate for a provider to separate these services into a second visit for either patient.) Anticipatory guidance is focused on health maintenance issues: alcohol and tobacco use, safe sex practices, nutrition, and exercise. The patient’s employment status and other family issues that may arise are discussed. As a patient grows older, cholesterol levels, blood sugar, and prostate-specific antigen (PSA) testing come into play. This is also the time to address advance directives with the patient.

Rule 4: Separate Services/Procedures Call for Separate Reporting

A preventive visit includes routine screenings such as a tuning fork hearing assessment and a visual acuity screening. Many other services that may be provided at the time of a preventive visit, however, are not included.

The immunization supply and administration laboratory and radiology services, electrocardiograms, and other services with an identifiable CPT® code can be billed in addition to the appropriate preventive service visit code. Remember to append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service in this scenario, to identify the preventive medicine E/M service as separate and distinct from other procedures or services provided to the same patient on the same day.

For example, a 45-year-old established female patient presents for her annual physical examination. While there, she complains her left ear feels “plugged.” During the course of the history and physical (H&P), the provider observes significant cerumen buildup, and has the nurse flush the patient’s ears. In this situation, both services may be billed with a modifier 25 appended to the annual physical (i.e., 99396-25, 69210 Removal impacted cerumen (separate procedure), 1 or both ears).

What if, during a preventive visit, a new problem is encountered or an existing problem requires attention? The American Medical Association (AMA) gives direction for these occasions in the CPT® guidelines, as follows:

“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.”

Remember: In a case such as this, you would append modifier 25 to the office visit code.

“Significant” is the key word here. A preventive visit requires a comprehensive history and examination of the patient. Any work done to support the additional E/M code has to be above and beyond what is already documented to support the preventive code billed. If the criteria are met and an E/M office visit code is billed, be certain to provide an appropriate ICD-9 code to support the additional service.

For example, a 19-year-old established male presents for his annual physical. He asks the provider to look at his right ankle. He states he twisted it snowboarding last night, and it is “killing him.” In addition to performing a routine H&P, the provider conducts an expanded problem-focused history relevant to the injury, and performs an expanded problem-focused knee exam. The provider diagnoses an ankle sprain, but wants to rule out a fracture. He orders an X-ray and instructs the patient to rest, apply ice, and elevate the ankle. The provider then writes a prescription for pain medication and tells the patient he will be contacted with the X-ray results.

In this situation, both the annual physical, 99395 with V70.0, and the appropriate level E/M office visit code (for example, 99213-25) with diagnosis 845.00 Sprains and strains of ankle, unspecified site may be billed.

Beverly Welshans, CPC, CPC-I, CPC-H, CCS-P, is compliance coordinator for University Orthopaedics, University Family Medicine, and University Physical Medicine & Rehabilitation Services at the State University of New York (SUNY) Buffalo School of Medicine. She has held numerous officer positions in her local chapter, and serves on the National Advisory Board.

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2 Responses to “Take Four Steps Toward Preventive Medicine Coding Success”

  1. Jennifer Phillips says:

    “For example, a 45-year-old established female patient presents for her annual physical examination. While there, she complains her left ear feels “plugged.” During the course of the history and physical (H&P), the provider observes significant cerumen buildup, and has the nurse flush the patient’s ears. In this situation, both services may be billed with a modifier 25 appended to the annual physical (i.e., 99396-25, 69210 Removal impacted cerumen (separate procedure), 1 or both ears).”

    This is incorrect information. I understand this is an older article, but even in 2010 this would not have been the correct way to code this visit. Code 69210 is only to be used when the physician removes the cerumen with an instrument. When the nurse “flushes” the patient’s ears, this is part of the E/M service.

  2. erin becker says:

    hi I was wondering if there are different codes to report for the preventive medicine codes when billing for hospitalists in inpatient & observation settings? Thank you

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