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Preventive Medicine with E & M

  1. Question Preventive Medicine with E & M
    Medical Coding Books
    When billing for a Preventive Medicine visit and an E & M visit where the criteria is met for both to be billed, if the Preventive Medicine code that is used is for a new patient, is the office visit E & M also billed with a new patient code? Thanks.

  2. #2
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    I would say no to this since you can only be a new patient once. I have seen other coders on this forum say you can bill both as new. But you are getting all the new background/history info on this patient and doing more work within the Prev visit so I would charge that one as new and the e/m as established. Hope that helps you.

  3. #3
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    Yes...this topic has been highly debated in the past. Per CPT Assistant Oct 2006...


    Evaluation and Management

    Question: If a preventive medicine service (99381-99397) and an office or other outpatient service (99201-99215) are each provided during the same patient encounter to a new patient, is it appropriate to report each evaluation and management (E/M) service as a new patient visit? Or is it appropriate to report the preventive medicine service as a new patient and the acute visit (ie, office or other outpatient service, 99201-99215) as an established patient?

    AMA Comment:It is important to first take careful note of the New and Established Patient instructions provided in the E/M services guidelines .

    Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    Therefore, if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.

    If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate).


    Although the question is from 2006, current CPT guidelines still indicate to report 99201-99215 as appropriate. Whether the carrier will pay or not is another story.

  4. #4
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    Quote Originally Posted by kstuber View Post
    When billing for a Preventive Medicine visit and an E & M visit where the criteria is met for both to be billed, if the Preventive Medicine code that is used is for a new patient, is the office visit E & M also billed with a new patient code? Thanks.
    The rationale used with many payers is, they're only new once. The CPT instructions are very confusing in their reference to 99201 - 99215 (implying that you can use a new P/O E/M w/a new preventive E/M) - I wish they would change that verbiage, honestly. The payer's rationale makes sense -
    With a problem and preventive E/M at the same time, the preventive E/M is considered the more comprehensive procedure; you have to go above and beyond it to bill a problem-oriented E/M on the same DOS, (which is also why the P/O E/M requires the 25 modifier, and not the preventive service.)
    So, technically speaking, the preventive E/M comes "first" for claim processing. Once that charge has been considered, the patient has officially received a 'professional service' from the provider, thus meeting the definition of an established patient for the purposes of choosing the problem E/M.

    That logic's not perfect, but it fits with the guidelines for new/estb. patients better than the guideline in the book, and as Rebecca mentioned, that's usually how payers view it. It wouldn't be any different if both visits occurred at once, or if the patient had a well check in the morning and came back that afternoon with a problem. I actually had a pretty big debate with a clinic manager over this issue, because they didn't agree with the denial based on CPT guidelines - it's hard to explain that neither side is technically 'wrong' - both interpretations of the guidelines work, but commercial payers have the discretion to interpret the rules as they please, so they'll get the final word in the matter. Most have policies about this somewhere in their disclosure notices/coverage guidelines, so check out their website to see if you can find it.

    This isn't an issue I'd bother trying to appeal, if I were you - it's not worth the trouble to get a few extra bucks added to the 50% of the allowable reimbursement you're going to get for the second E/M, anyways. Hope that helps!

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    Thanks everyone for your input. You have been a great help.

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