EM Coding Alert

You can report a problem with preventive but you need to support it in documentation.

Failing to recognize a preventive care service along with a problem-oriented service means you could be leaving money on the table. Spotting the components of a preventive care visit in the note will keep you from overlooking deserved reimbursement.

Review the following expert pointers to learn when to separate a preventive from a problem-oriented visit.

Pick From Initial or Periodic

There are two ranges of preventive E/M codes. One range, 99381-99387 (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; …), you use with the initial preventive visit of a new patient.

The other range, 99391-99397 (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; …), you use for periodic preventive established patient visits.

Preventive visits differ from problem-oriented visits because the preventive history and exam focus on the patient as a whole, not only the current issue.

“The preventive medicine E/M service is not a problemoriented service and does not involve a chief complaint or present illness history,” says Jacqueline Mehalich, RN, CPC, CPC-H, manager of physician education at Allegheny Health Network in Pittsburgh, Pa. When reviewing your provider’s documentation, you need to ask yourself the following questions to determine which set of preventive codes applies:

•  Is the encounter the patient’s initial preventive visit or is it a periodic preventive visit?
•  Is the patient new or established?
•  What is the age of the patient?

Review the Components of a Preventive Visit

Knowing what components make up a preventive encounter will help you distinguish between a preventive and problem-oriented visit in the note. The components may include:

• Review of medical and social history
• Height, weight, body mass index, and blood pressure
• Simple vision test
• Review risk factors for depression
• Review functional ability and level of safety, hearing assessment, ability to perform activities in daily life safely and successfully
• Educate and counsel patient on staying well
• Additional screenings if necessary.

The examination component for a preventive care visit differs from the exam given in a problem-oriented visit. The CPT® manual states that “The ‘comprehensive’ nature of the preventive medicine service codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the ‘comprehensive’ examination required in evaluation and management codes 99201-99350.”

Watch for Separate Services

If your physician performs a preventive service and then a patient brings up a problem that requires additional work, you can report both a preventive and a problem-oriented service as long as the documentation supports the need for both services. You would report the preventive code and the problem-oriented code with 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) attached to the problem-oriented code.

“These preventive services can be, and usually should be, rendered outside of an E/M service described by 99201-99215,” says Freda Brinson, CPC, CPC-H, CEMC, compliance auditor at St. Joseph’s/Candler Health System in Savannah, Ga.

Example: Your physician sees a 38-year-old established patient for a routine annual physical (99395, 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; 18-39 years). During the physical, the patient brings up that she has had intermittent abdominal pain not associated with any foods or activities. Therefore, your doctor performs additional work required by the key components of a problem-oriented E/M service.

You will report 99395 for the preventive care visit and the correct problem-oriented E/M code from the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient...) range based on the documented history, exam, and medical decision making. Attach modifier 25 to the problem-oriented code to communicate to the payer that this is a separately identifiable E/M service.

Be careful: Because preventive coding includes counseling, anticipatory guidance, and/or risk factor reduction interventions, you do not make the mistake of trying to code counseling separately. Your physician needs to document clearly, the details supporting the problem-oriented visit and the preventive visit.