Pediatric Coding Alert

Question: Is medication management included in a preventive medicine visit? And if it isn’t, can we bill for the preventive visit and an office evaluation and management (E/M) visit at the same time if medication management occurs?

AAPC Forum Participant

Answer: CPT^® guidelines and the code descriptors for preventive medicine E/Ms 99381-99396 (Initial/periodic 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 …) do not mention medication management as a component of the service.

Similarly, CPT^® does not include medication management as a part of risk-factor reduction services 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …) or behavior change intervention services 99406-99407 (Smoking and tobacco use cessation counseling visit …), 99408-99409 (Alcohol and/or substance … abuse structured screening …), and 99411-99412 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting …).

That’s because these codes “are used for persons without a specific illness …” according to CPT^®. Medication management implies that the patient has a specific illness.

But this does not mean you can bill for an office/outpatient E/M and a preventive medicine E/M when your pediatrician manages a patient’s medications during a preventive visit. CPT^® guidelines for preventive medicine services tell you that if “a pre-existing problem is addressed in the process of performing this preventive medicine E/M 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 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) should also be reported.”

In other words, to bill a 99202-99215 E/M service for medication management separate from a preventive E/M service, the pediatrician must perform “additional work” consisting of the “key components of a problem-oriented E/M service.” Per current office/outpatient E/M descriptors, that means the provider has to perform a “medically appropriate history and/ or examination, which your documentation must show are separate from the ‘age and gender appropriate history’ and ‘examination’ associated with 99381-99396 if you are billing those services as well.”

Additionally, if you are billing a separate 99202-99215 using medical decision making (MDM), you will need to document a second element of MDM to justify the level of service. The prescription drug management will, of course, count only as the element of risk of complication and/or morbidity or mortality of patient management category at the moderate MDM level.

And remember: In order to show the office/outpatient E/M is significant and separate from the preventive visit, you 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 office/outpatient E/M.