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.

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® 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.

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