Wiki E/M Bill with Preventive Care


Denver, CO
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Can someone help me on how to explain to a Doctor when to bill e/m with preventive service? The Doctor seems to think that if the patient has extra minor issues it is okay to bill an e/m. For example the Doctor discuss with patient weight gain or somethng minor. I have tried to explain inorder to bill a e/m code with a preventive service you must go above and beyond the preventive care.

Also when billing an e/m with preventive service should there be a seperate documentation including the HPI, ROS, PFSH and Exam so you can select the level of service? Or can you go off of the mdm for the e/m and the preventive care exam?

Thanks in advance:eek:
E/M with Preventative

Check out the following article

"When a patient comes into the office for a routine preventive examination and also has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a combination of preventive and problem-oriented care. As long as the problem-oriented service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam and the appropriate office visit code (99201-99215) with modifier -25, "Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service," attached to the problem-oriented service. It's also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services. (See the example of a preventive E/M visit with a problem-oriented service, and for more on ICD-9 codes, see "Using diagnostic codes effectively.")"

Hope this helps
CPT Guidelines

CPT Guidelines:

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management 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 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.
trivial condition vs non trivial?

What would be considered trivial/minimal condition that could not be included as an e/m visit during a preventive maintenance exam? Our providers see patients with impacted cerumen, sinus infections, strep throat. Sometimes labs are done associated with these symptoms or removing the impacted cerumen with a curette. Does this constitute the use of both e/m and exam code including the 25 modifier? I have gotten denials from Medicaid under these situations. Thanks for your expertise!
In order to appropriately assign a preventative medicine service along with a problem oriented service, the clinical record must provide additional information to the support the current problem.

The problem must not be inclusive to the preventative medicine service visit (i.e., stable pre existing/chronic diagnoses) but instead be a new complaint or worsening previously diagnosed condition.

The additional effort provided by the physician should be clearly documented within the medical record in order to differentiate the CPE from the problem oriented service (the key component criteria must be met, 1995/1997 Documentation Guidelines).

(CPT AMA guidelines state that we must specify in our documentation that the problems were significant enough to require additional work for each key component).

Here is an article that I thought might be helpful.

Official CMS Information - Evaluation and Management Service Guide
I have a visit where the patient came in for a well exam; there is no mention of any other complaints in the CC/HPI. The doctor documented a red throat under the Exam and did strep tests. Can I bill a problem-oriented E&M in addition to the well exam here?

Thank you very much.
I will try my best to help.

This is difficult to answer without seeing the chart documentation but I will try my best to help.

The first thing we need to determine is if this is a new or established patient. If the patent is new then 3 out of the 3 key components must be met in order to warrant an additional office visit. If this is an established patient than 2 out of 3 key components are required.

History component - You stated that "there is no mention of any other complaints in the HPI" After reading through the entire chart note can you find anything else to support an HPI element? Did your physician perform a ROS, any positive statements (patient has a sore throat)?

Exam component - Red throat, did the patient have a fever?

Medical Decision Making - strep test (positive/negative?) What did the provider diagnose the patient with? How did he treat the patient for this condition (antibiotics/OTC)?

If you can provide me the answers to the above questions then I can help you determine if an additional office visit is warranted.
I'm sorry - this is an established patient.

The only documentation in the note regarding the sick complaint is "throat red" under Exam and the two strep tests (negative) that were done. The doctor adds 462 Acute Pharyngitis as a second diagnosis.

A comprehensive ROS was done as this was a well exam. No positive statements.

In general we only code the sick visit in addition to the well visit if it is an established patient since 2 of 3 key components is all that is necessary. Since we do not have a separate note for the well exam and a separate note for the sick exam and there is always a comprehensive ROS and Exam done for the well exam, we don't know what was done for the sick portion of the visit. That leaves us with CC/HPI and MDM (unless there is a notation under exam regarding the sick complaint - but that would usually only be one system) which equals a 99212.

The reason I am asking in this case is because technically we do have enough documentation to support the 99212. So I coded the well exam and the 99212. Insurance processed with a copay and I had to tell this to the patient's father who called today. Somehow it doesn't seem right to charge the patient if the patient didn't have a complaint to begin with and the sore throat was only come across during the well exam.

Thank you so much for all your help.
You are welcome

A lot of the offices I have worked for will actually give a patient a hand out explaining what is considered a preventative service and what falls under diagnostic. Educating the patients can help them better understand their plan and benefits. This started because there was an influx of patients calling to dispute the copayment amount stating "I was only there for my physical exam", "I shouldn't have a copay". Then the coding department has to audit the documentation all over again to see if the additional office visit was truly warranted.

If the physician provided additional work that was not inclusive to the preventative exam he deserves to be compensated. As a rule of thumb when auditing in this situation I usually jump straight to the assessment and plan. It helps to see how/what condition was diagnosed and treated. Then I can go over the history and exam and pull out what applies to the diagnosis that was treated.

This article might be helpful:

It is important to remember that "the ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. In theory, the ROS may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention to the physician."
Does anyone by chance have signage in the office explaining to patients they may have two charges if an E/M is billed with preventive? If so, could you share or know of a site which has a sample?

If the patient is coming in for preventive care and the provider refills medication for thier chronic problems (HTN, HLD, DM). The chronic problems are stable and the patient has no new complaints. The provider orders routine labs for the stalble chronic conditions; as well as screening services for preventive visit. Would it be appropritate for the provider to bill an sperate E/M for the chronic stable problems? Please help