Revenue Cycle Insider

Hint: Rely on E/M codes for commercial payers and HCPCS for Medicare.

Preventive care visits may not fully constitute the bread-and-butter revenue for every primary care office, but they are a crucial part of patient care, and they certainly contribute to the bottom line.

Documentation for preventive services is fundamental for receiving appropriate reimbursement, and is also the foundation of coding, protects patients and providers, and can be used for audit support and for checking on Healthcare Effectiveness Data and Information Set (HEDIS) measures, said Kelly Shew, CPC, CPCO, CDEO, CPB, CPMA, CPMS, CRC, CEMC, CGIC, CPEDC, CRHC, in her 2025 DOCUCON deep dive presentation “Preventive Care: Documenting for Payment, Performance, and Compliance.”

Here’s a primer on some common codes for reporting preventive services for patients with commercial insurance, as well as Medicare beneficiaries.

Know Which E/M Codes Cover Preventive Care

Evaluation and management (E/M) new patient codes 99381-99386 (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 …) and established patient codes 99391-99396 (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 …) are commonly used to report annual preventive care visits for patients 0-64 years old with commercial insurance. Remember, Medicare and Medicaid do not pay for annual physicals, Shew said, as they have other designated services for their beneficiaries.  

Most primary care providers (PCPs) are familiar with the phenomenon of patients bringing up new or ongoing concerns unrelated to the preventive care visit, and to receive payment due for other concerns addressed, documentation needs to clearly support both the services performed for the preventive visit and the services rendered for the other concern(s). When guideline criteria are met, this can often be accomplished by appending a modifier, like 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).

“They should not overlap. You can’t claim something for both pieces, but they can be done assuming the documentation supports. If that’s the case, modifier 25 should be added to the E/M portion of the service,” Shew said. If the visit transitions to focusing on the additional concern, there may not be enough documentation to support the preventive medicine service, Shew warned, which coders should take into consideration.

Top tip: “Comprehensive for the preventive medicine codes does not have the same meaning as comprehensive in E/M coding,” Shew said. The respective guidelines apply to two different sets of data.  

Be Familiar With the Medicare and Medicaid Annual Codes

Medicare covers initial preventive physical exams (IPPE) for eligible new beneficiaries, which is a once-in-a-lifetime visit that you can report with HCPCS code G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment).

“This is really to go over medical and social health histories, preventive services education, collecting information — ‘Do you have a living will? Do you have a beneficiary?,’” Shew described. “Even though the doctor may have been seeing this patient their entire adult life, this is kind of setting them up for the Medicare side of things, and really congealing all of the information into this one visit.”

After the IPPE, Medicare beneficiaries can look forward to annual wellness visits (AWV). There’s an initial AWV, which you can report with G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) and then the regular, subsequent AWV, which you can report with G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit).

Don’t Get Tripped Up by Noncoverage

It's important to make sure providers understand what Medicare AWVs cover, because elements of care that aren’t covered will be denied, and the cost of the services may be transferred to the patient, depending on the paperwork the beneficiary may have signed.

Shew said PCPs should think about AWV as a hands-off visit. “We are not actually assessing the patient’s current health — we’re kind of assessing: Do they have all they need in place in order to continue living as they have been living? Do they have the social services that they need? Do they have resources available to them?” Shew explained.

While some PCPs like to work a physical examination into the AWV too, an AWV is more like a meeting to check in on the big picture rather than gather biological or physical data on a patient’s current condition. For provider education purposes, it can be helpful to do an audit of chart notes and see together how the costs of services for each patient may be transferred to them, if the services don’t align with Centers for Medicare & Medicaid Services (CMS) payment.

Still, if a Medicare beneficiary comes in with additional concern that the PCP wants to assess/address, there are options for documenting separate services. Shew said that in such a situation, a coder would report the additional CPT^® code, along with modifier 25.

“Your office visit code and your AWV both need to have documentation to support each service,” Shew said. She said it works for some providers to enter separate notes into the chart for the preventive service and then the distinct concern.

However your PCP documents the preventive care provided, make sure you know which CPT^® or HCPCS codes are appropriate to report the respective service.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC