Same-day Preventive and E/M Services

Same-day Preventive and E/M Services

Sometimes, at a scheduled preventive visit, the patient mentions a new or worsened condition. If the patient complaint requires additional workup, beyond that usually associated with the preventive service, you may choose to report a problem-focused visit in addition to the preventive service.
The CPT® codebook 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.

Documentation must support both services. Any work performed for the preventive service does not count toward the E/M service. A separate HPI (history of present illness) describing the patient’s complaint supports additional work in the history. If a portion of the exam performed is not routine for a preventive service, identify that portion.
When reporting the preventive visit and a problem-focused visit on the same day, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service to the problem-focused visit code.
Commercial payers’ policies vary. Some will not pay for more than one E/M service on one date of service. Check with payers to verify coding policy and patient benefits.

John Verhovshek
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About Has 569 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

No Responses to “Same-day Preventive and E/M Services”

  1. Debra Mitchell says:

    If the patient expresses a symtom/concern at the time of an asymptomatic wellness visit, the category heading and the excludes 1 note does not allow reporting these together. The cater of Z00 states encounter for general withou complain, suspected, or reported diagnosis. The excludes 1 note states encounter for signs and symptoms – report to the signs and symptoms. This is not one of the excludes one notes they were addressing with the temporary exception. You cannot make a case that a patient presented and was both symptomatic and asymptomatic at the same time. The choice that states with abnormal finding must show that the patient presented asymptomatic and something abnormal was discovered by the provider during the encounter.

  2. Alicia Perez says:

    If a preventative care visit was completed with vaccinations, and a sick visit on the same day, do we add modifier 25 to the sick visit, or both the sick and prev care visit?

  3. Yolanda Fletcher says:

    I wanted to know if 99395 is bundling with any of the other codes if it is how can I unbundle it this is what I submitted:
    99395 w/dx Z00.00 (Ins. did not pay)
    99214 w/dx R53.83,S46.912A,S29.012A (Ins. paid)
    98925 w/dx S46.912A,S29.019A (Ins. applied to deductible)
    96372 w/dx R53.83 (Ins. paid)
    J3420 w/dx R53.83 (Ins. paid)