Medicare Compliance & Reimbursement

Appropriate modifier use could help break bundling of services.

Normally you’ll code preventive wellness visits by choosing the best option based on the patient’s age and whether she is a new or established patient. Your code choices are:

• 99381-99387 (Initial comprehensive preventive medicine evaluation 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, new patient …) or
• 99391-99397 (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 …).

Don’t file the claim, however, before checking for the following other services your physician might provide during the encounter that you can bill separately.

1. In-Office Laboratory Tests

Simply ordering a lab test during a patient’s preventive care visit cannot be separately coded. But if it’s a test your staff completes in the office, you can bill for the test in addition to the visit, says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Ks.» »

Example: The physician runs a lab test to check the patient’s hemoglobin. You can report 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]) for taking the sample and 85018 (Blood count; hemoglobin [Hgb]) for the actual test. Remember that the payer might require you to 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 preventive visit code.

2. Hearing or Vision Screenings

Some types of screenings can be reported with preventive care visits, depending on the exact service.

Examples: The physician performs a hearing screening that falls under code 92551 (Screening test, pure tone, air only). Or, you could report a vision screening with a code such as 99173 (Screening test of visual acuity, quantitative, bilateral).

3. Immunizations

Physicians often administer vaccines on the same day as a well/preventive care visit. If so, you’re allowed to separately report the appropriate immunization administration code (such as 90471, Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine [single or combination vaccine/toxoid]) as well as the code for the vaccine product itself, assuming the vaccine product represents a cost to your practice.

For example, if a patient needed an influenza shot while in the office for his or her annual preventive medicine visit, you would report 90471 plus the appropriate CPT^{® code for the type of influenza vaccine that you administered.}

^{Note: NCCI edits bundle some E/M services with an immunization administration code billed on the same date unless an appropriate modifier is appended to the E/M code. Be sure to append modifier 25 to the preventive medicine code in this scenario to ensure that you get paid for it in addition to the vaccine administration.}

^{Editor’s note: One of the most common scenarios for services you can bill in addition to preventive care is when the patient brings up a new problem during the visit. For more on this topic, see "Boost Pay With These Savvy Tips" in Medicare Compliance & Reimbursement, Vol. 39, No. 10.}