Successfully Report Preventive Medicine Services

Here are three tips to help you report preventive medicine services successfully.

Tip 1: Diagnosis Must Reflect the Reason for Visit

Always match preventive medicine codes with an appropriate diagnosis. A preventive medicine service is not a problem-oriented visit, and shouldn’t be coded as one. Instead, use an ICD-9 code that supports the services provided: 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) may be used, as appropriate.

Tip 2: Coding Must Reflect Patient Status

CPT® includes preventive medicine codes for new (99381-99387) and established (99391-99395). Per the “three-year rule,” if the patient has not seen the provider (or a provider of the same specialty in the billing group) within the past three years, the patient is new. All other patients are established.

CPT® further defines the preventive medicine codes by patient age:

  • Younger than one year — 99381 (new) and 99391 (established)
  • One through four years — 99382 (new) and 99392 (established)
  • Five through 11 years — 99383 (new) and 99393 (established)
  • 12 through 17 years — 99384 (new) and 99394 (established)
  • 18 through 39 years — 99385 (new) and 99395 (established)
  • 40 through 64 years — 99386 (new) and 99396 (established)
  • 65 years and older — 99387 (new) and 99397 (established)

Tip 3: Not all Preventive Services Are the Same

Preventive medicine services always include a comprehensive history and examination, and age-appropriate anticipatory guidance. The comprehensive examination reflects the type of assessment required, as determined by the patient’s age and sex

For example, the exam for a two-year-old child and a 25-year-old woman will (not surprisingly) differ. Services for a young child will assess physical growth (height, weight, head circumference), and milestones of development such as speech, crawling, and sleeping habits.

Preventive services for an adolescent may include a scoliosis screen, assessment of growth and development, and a review of immunizations. Anticipatory guidance may focus on health habits and self-care, perhaps including a discussion of drugs, alcohol, and tobacco, and sexual activity.

A comprehensive preventive visit for an adult female patient will include a gynecologic examination, Pap smear, and breast exam. An adult male’s exam would include an examination of the scrotum, testes, penis, and the prostate (for older patients). Anticipatory guidance may focus on issues of health maintenance: alcohol and tobacco use, safe sex practices, nutrition, and exercise. As patient age advances, cholesterol levels, blood sugar, and prostate-specific antigen (PSA) testing come into play.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

5 Responses to “Successfully Report Preventive Medicine Services”

  1. Lana Schaffhausen says:

    I like this. It helps to read and refresh guidelines that sonetimes get forgotten.

  2. Aisha Cheong Hussain says:

    Very helpful as refresher in guidelines.

  3. Michele Price says:

    Is a pelvic exam require for a Comprehensive Preventative gynecological well women exam as well?

  4. Ben Jones says:

    why is so much educational material on the AAPC website way out of date – sometimes several years old, counter productive for coders.

  5. Brad Ericson says:

    Hi Ben –

    We leave it for up for three reasons: 1) Not all articles are out of date; 2) Some coders are looking for material from the past for auditing and other reasons; and we don’t have the resources to check every article for currency after it’s posted.

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