Separately Billable Services/Procedures with Preventive Medicine Visits

Preventive medicine visits (99381-99387 for new patients and 99391-99395 for established patients) include routine screenings, such as a tuning fork hearing assessment and a visual acuity screening. Per CPT® guidelines, many other services that may be provided at the same visit are separately billable.

For instance, you may bill the supply and administration of immunizations, laboratory and radiology services, electrocardiograms, and other services with an identifiable CPT® code in addition to the appropriate preventive service visit code.

When appropriate, you may also report a problem-focused E/M with the preventive medicine visit. Per CPT® instruction:

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.

“Significant” is the crucial condition, here. A preventive visit requires a comprehensive history and patient exam; therefore, effort to support the additional E/M service must be beyond that already documented to support the preventive medicine visit already performed. In such a case, you also must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the problem-focused E/M service code, and you must provide an appropriate ICD-9 code to support the additional service.

To demonstrate, consider the following vignette, quoted from the AMA’s August 1997 CPT Assistant:

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A 33-year-old established female patient presents to the physician’s office for her yearly gynecological examination. During the examination, the physician identifies a palpable, solitary lump in the right breast.

The physician considers this finding significant enough to require additional work and the performance of the key components of a problem oriented E/M service. Therefore, CPT code 99395 [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; 18-39 years] would be reported for the preventive medicine services visit, and an additional code (99212-99215) would be reported for the problem oriented E/M service related to the breast lump.

The appropriate problem oriented level of E/M service should be selected based on the key components associated with providing the problem oriented E/M service. For established patients office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. Modifier -25 would then be appended to the office visit level of service reported, to indicate that a significant, separately identifiable E/M service was provided. The ICD-9-CM diagnosis codes reported should also reflect the services provided.

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 404 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.

One Response to “Separately Billable Services/Procedures with Preventive Medicine Visits”

  1. CHRISTY MANSUY, CPC says:

    Please define ‘additional work’.

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