Primary Care Coding Alert

Preventive service is a classic example of an area where good medicine doesn t necessarily result in good reimbursement.   During the course of a year, family physicians (FPs) perform scores of preventive exams or annual physicals (99381-99387, initial preventive medicine; 99391-99397, periodic preventive medicine), which medical professionals agree are vital to a patient s health and well-being. However, most insurers  including Medicare  won t cover annual checkups, instead shifting the financial burden to the patient and creating a disincentive for patients to see their physicians regularly.   Family practices can counteract this problem by recognizing when a preventive service is simply an annual checkup  and when all or portions of the encounter can be coded and billed as an office or outpatient visit that will be paid by the insurer. These situations may occur when a problem or condition is discovered during a preventive exam, or when the visit can legitimately be considered necessary surveillance of chronic conditions.   What Constitutes Classic Preventive Service   FPs and coders must first recognize circumstances when only a preventive service may be reported. Typical annual checkups may include well-woman care with a breast exam and Pap smear, periodic sports or school physicals, and annual checkups for patients who raise no noteworthy concerns during the visit.   For instance, a 55-year-old male is seen for his checkup and asks the physician to inspect areas on his hands and arms where the skin has darkened. During the overall physical examination the FP notes that the change is simply discoloration due to aging. In this instance, because no significant new problems were evaluated or treated, only 99396 (periodic preventive medicine, 40-64 years) may be reported.   Coding When Visits Become Problem-oriented   Coding becomes less straightforward when new conditions are evaluated during a preventive service. FPs and coders must recognize when the patient introduces a complaint that requires a significant and separately identifiable service, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J. When this occurs, physicians may report both a preventive service code and an outpatient visit code.  However, simply discussing a problem during the checkup doesn t automatically mean it can be billed as a separate E/M service, she warns. Instead, it must be clear that the doctor is proactively evaluating and treating another problem.   During her well-woman exam, for instance, a 30-year-old established patient complains of mild vaginal itching and discharge. The FP questions the patient further about her symptoms and, upon examination, diagnoses vaginitis (616.10). The physician recommends that the patient purchase over-the-counter suppositories from the pharmacy, advising her to return if the condition hasn t cleared up in a few [...]