davecripps
New
Subject: Preventive Visit/AWV Initiated During a Problem-Focused Encounter?
I am looking for guidance, preferably with CPT Assistant, AMA, CMS, or other authoritative references, regarding preventive medicine services (99391-99397) and Medicare Annual Wellness Visits (G0438/G0439) that are performed during encounters that were initiated for a problem or complaint.
We have a disagreement between our coding department and some providers regarding whether a preventive medicine service or AWV can be reported when the patient presents for evaluation of a condition and the provider then decides to perform preventive services during the same encounter.
Example:
A patient schedules an appointment for vaginal itching. During the visit, the provider spends only a few minutes addressing the itching but then performs what they consider a complete annual exam, including preventive history, screening recommendations, Pap smear, preventive counseling, and preventive labs.
The provider's position is that the "intent" of the visit should be determined by what was actually performed and documented during the encounter. Therefore, if the majority of the visit becomes preventive in nature, they believe the preventive medicine service (or AWV) should be billable, with or without a separate E/M service.
The coding team's position is that preventive medicine services and AWVs are intended to be preventive encounters. If the patient presents with a complaint or problem requiring evaluation, the encounter is initially problem-oriented. In that situation, a separate preventive service would need to independently meet all requirements and be clearly distinguishable from the problem-oriented work. We are concerned that routinely converting problem-focused visits into preventive visits solely because preventive services were also performed could create audit risk.
A few questions for the group:
Thank you for any insight.
I am looking for guidance, preferably with CPT Assistant, AMA, CMS, or other authoritative references, regarding preventive medicine services (99391-99397) and Medicare Annual Wellness Visits (G0438/G0439) that are performed during encounters that were initiated for a problem or complaint.
We have a disagreement between our coding department and some providers regarding whether a preventive medicine service or AWV can be reported when the patient presents for evaluation of a condition and the provider then decides to perform preventive services during the same encounter.
Example:
A patient schedules an appointment for vaginal itching. During the visit, the provider spends only a few minutes addressing the itching but then performs what they consider a complete annual exam, including preventive history, screening recommendations, Pap smear, preventive counseling, and preventive labs.
The provider's position is that the "intent" of the visit should be determined by what was actually performed and documented during the encounter. Therefore, if the majority of the visit becomes preventive in nature, they believe the preventive medicine service (or AWV) should be billable, with or without a separate E/M service.
The coding team's position is that preventive medicine services and AWVs are intended to be preventive encounters. If the patient presents with a complaint or problem requiring evaluation, the encounter is initially problem-oriented. In that situation, a separate preventive service would need to independently meet all requirements and be clearly distinguishable from the problem-oriented work. We are concerned that routinely converting problem-focused visits into preventive visits solely because preventive services were also performed could create audit risk.
A few questions for the group:
- For CPT 99391-99397, does the patient's reason for presenting (chief complaint/presenting problem) affect whether the preventive medicine service is supported?
- Are there CPT Assistant, AMA, CMS, or Medicare Contractor references that discuss whether preventive medicine services can be initiated during encounters that begin as problem-focused visits?
- Does the same analysis apply to Medicare Annual Wellness Visits (G0438/G0439), or can an AWV be performed and billed when the patient presents primarily for evaluation of an illness or complaint?
- How are your organizations handling situations where a patient is scheduled for a problem-focused visit but the provider decides to perform an annual preventive exam or AWV during the same encounter?
Thank you for any insight.