Recommended Ways to Document and Report a Preventive Visit

Recommended Ways to Document and Report a Preventive Visit

Follow best practices to meet annual exam documentation requirements.

By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, CSCG, AAPC Fellow

Unlike other evaluation and management (E/M) services in the CPT® codebook, preventive services do not have specific documentation guidelines required to support the service provided. Here’s what you should know to ensure documentation supports these services.

Evaluation and Management – CEMC

Preventive Service Codes

The American Medical Association’s (AMA) CPT® code set describes the annual preventive exam as a periodic, comprehensive preventive medicine evaluation (or reevaluation) and management of a patient. Codes 99381-99397 represent these services, and their selection is based on whether the patient is receiving an initial (new patient) or a periodic (established patient) preventive service, as well as the patient’s age.

CPT® Code Description
99381 Initial comprehensive preventive medicine evaluation and management, 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, 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

CPT® further describes the services to include, “an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”

Defining “Comprehensive” 

A preventive medicine service is comprehensive in nature; however, the “comprehensive” nature of these services should not be confused with the comprehensive examination requirements in other E/M codes.

When determining if the physician or other qualified healthcare provider’s documentation supports a preventive medicine CPT® code, the question of how these services should be documented inevitably comes up, along with many other questions:

  • What information should constitute a comprehensive history?
  • What equates to an age- and gender-appropriate examination?
  • What counseling, anticipatory guidance, and risk factor reductions should be addressed?
  • What laboratory and diagnostic procedures are relevant to a preventive service?
  • What documentation should appear in a patient’s medical record to support the billing of a preventive medicine E/M service?

Although there are no official, specific documentation guidelines for these services, based on recommendations from the AMA, the American Academy of Family Physicians, the U.S. Preventive Services Task Force, the American College of Physicians Internal Medicine, and the American College of Obstetrics and Gynecology, here is a breakdown of the information you should see documented in the review of a preventive medicine service based on the patient’s age and gender:

Well Baby Visits – Birth to 2 Years

History: Past illnesses, surgeries, medications, allergies, in utero/birth history, family and social histories

Exam: Hearing for newborns, weight, length, head circumference, head, chest, abdomen, genitalia, neck, extremities, eyes, ears, nose, throat (ENT), cardiovascular, respiratory, skin, neurological

Counseling/Anticipatory Guidance: Safety, health, nutrition, development, immunizations, injury prevention

Risk Factors: Age appropriate developmental and behavioral assessments

Screening Services: Hemoglobin or hematocrit once between 9-12 months, phenylketonuria (PKU) screening, oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, hearing screening before one month of age, screening for sickle-cell disease

Well Child Visits – 3 to 10 Years

History: Past illnesses, surgeries, medications, allergies, family and social histories

Exam: Blood pressure, vision screening, hearing screening, height, weight, body mass index (BMI) with percentile for age, eyes, ENT, cardiovascular, respiratory, gastrointestinal (GI), genitourinary (GU), musculoskeletal, skin, neurological, psychological

Counseling/Anticipatory Guidance: Safety, injury prevention, health, nutrition, development, immunizations, screenings

Risk Factors: Age appropriate developmental and behavioral assessments

Screening Services: Screening for obesity in children 6 years and older, vision screening

Well Child Visits – 11 to 18 Years

History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions

Exam: Blood pressure, vision screening, hearing screening, height, weight, BMI, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, avoidance of tobacco, alcohol and drugs, sexual behavior and sexually transmitted diseases (STD), dental health, mental health, immunization, screenings

Risk Factors: Hypertension, hyperlipidemia, coronary heart disease, depression, eating disorders, emotional, physical, or sexual abuse, problems with learning and school

Screening Services: Chlamydia for sexually active females, depression, obesity, HIV

Adult Visits – 19 to 39 Years

History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions

Exam: Blood pressure, height, weight, BMI, breast exam for women, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, family planning/contraception, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunizations, screenings

For Women: Breast cancer and self breast exams

Screening Services: Cholesterol every five years beginning at 20 years of age, chlamydia for sexually active women under 25 years of age, cervical cancer, HIV

Adult Visits – 40 to 64 Years

History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions

Exam: Blood pressure, height, weight, BMI, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, contraception, dental health, mental health, immunizations, screenings

Screening Services: Cholesterol, diabetes, colorectal cancer beginning at 50 years, HIV

For Women: Breast cancer, cervical cancer

For Men: Prostate cancer beginning at 50 years

Adult Visits – 65 Years and Older

History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions

Exam: Blood pressure, height, weight, BMI, hearing screening, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol, and drugs, sexual behavior, dental health, mental health, fall prevention immunizations, recommended screenings for age/gender

Screening Services: Cholesterol, diabetes, colorectal cancer

For Women: Breast cancer, cervical cancer, osteoporosis beginning at 65

For Men: Abnormal aortic aneurysm (one time for men 65-75 years with history of smoking), prostate cancer

What Services Must Include

Checking the status of chronic conditions and refilling on going prescriptions is expected during an annual preventive exam and do not warrant the billing of a separate problem-oriented E/M service. If a chronic condition is not being well controlled, however, and decisions are being made as to how to treat the patient to improve control (changing the dosage of medications, changing to a new medication, etc.), this may substantiate a separate problem-oriented E/M service. For example, more work is done (and documented) than what is performed normally during an annual preventive exam.

Remember: These are recommendations, only; the patient’s needs, history, and risk factors determine the extent to which counseling, anticipatory guidance, and screening services should be performed, based on the provider’s clinical judgment. For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended. What’s important is the documentation should include what counseling and anticipatory guidance was provided to each patient, as well as the screenings that were discussed and ordered or offered, should the patient decline. The documentation should very clearly show that the elements of the annual preventive service were met.


Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, CSCG, AAPC Fellow, has more than 18 years of medical billing and coding and consulting experience. She is a revenue cycle consultant for Visionary Health Group, Community Health Network, Indianapolis, Ind., who is primarily responsible for chart reviews and provider education. Risotti-Hinkle has taught billing and coding classes including the AAPC’s PMCC curriculum to prepare students for the CPC certification exam. She is a member of the Indianapolis, Ind., local chapter.

One Response to “Recommended Ways to Document and Report a Preventive Visit”

  1. Marlena Bleil says:

    I really liked this article. I have been looking for something I could share with my providers and coders. Question though, what do you say to providers that feel that ordering labs for chronic conditions to monitor or check status should support an additional E&M when billing for the preventive visit?

    Thank you

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