Q: What is the proper way to code for a new preventative visit and a new sick visit on the same date of service? Some say you cannot bill a new preventative and a new sick evaluation and management (E/M) code on the same day due to the overlap of history and exam. Some say you can and others say to bill the preventative as new and the sick as established, which is what Medicaid requires. Our office is divided three ways on this issue. Any supporting documentation would be greatly appreciated. Thank you.
A: Per CPT guidelines, if an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine E/M service, and if the problem/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. The E/M code report problem-oriented service should be based on the additional work performed by the physician. Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.
If a physician encounters an insignificant or trivial problem/abnormality in the process of performing the preventive medicine E/M service and it does not require additional work and the performance of the key components of a problem-oriented E/M service, then this should not be reported separately.
Medicare covers initial preventive physical examination (IPPE) effective Jan. 1, 2005. This "Welcome to Medicare benefit" must occur within the first 6 months (now 12 months) that a Medicare beneficiary elects to participate in Medicare Part B. The service is reported with G0344. Medicare also allows reporting a separate E/M code (99201-99215) when a separately identifiable service is provided. Some of the components of a medically necessary E/M service, for example, a portion of the history and physical (H&P) examination, may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary E/M service.
Some third-party payers may not follow CPT guidelines. Check with third-party payer reporting and reimbursement guidelines in your area when reporting both a preventive and a problem-oriented E/M service on the same day.
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