EM Coding Alert

Code descriptors only tell part of the story.

You know that preventive medicine E/M services are important, so you may be surprised to learn that “there are no official, specific documentation guidelines” for 99381-99396 (Initial/periodic 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 …) according to Ellen Hinkle, BS, CPC, CDEO, CPMA, CRC, CEMC, CFPC, CGSC, CIMC, COBGC, CPCD, AAPC Approved-Instructor, provider compliance auditor at Bon Secours Mercy Health Cincinnati, Ohio.

CPT^® descriptors for the services do offer some general guidance: they tell you to document an age- and gender-appropriate history and exam; counseling, guidance, or risk-factor reduction intervention; and any screens or tests your provider performs during preventive medicine encounters. But exactly what do each of these components entail? More, how should they be documented?

What Do Medical Associations Have to Say?

To find recommendations for documenting preventive care, you need to look beyond CPT^® guidelines. That means going to organizations such as “the AMA, the American Academy of Family Physicians, the U.S. Preventive Services Task Force, the American College of Physicians - Internal Medicine, and the American College of Obstetrics and Gynecology” for guidance, Hinkle advises.

Specific to pediatric preventive care, “the AAP [American Academy of Pediatrics] provides recommendations for preventive pediatric healthcare, which represent a consensus by the AAP and Bright Futures and are updated annually,” notes Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. The most current AAP periodicity schedule for pediatric preventive care can be found at downloads.aap.org/AAP/PDF/periodicity_schedule.pdf.

From these recommendations, we can start to see some consistent guidelines that you can use when you document preventive medicine services for your patients.

Recommendation 1: Document the History

Your documentation should note family and social histories; developmental milestones, such as walking and talking; sleep and food habits; alcohol and drug use; past illnesses; and updated information about surgeries and allergies.

Additionally, documenting and “checking the status of chronic conditions and refilling ongoing prescriptions is expected during an annual preventive exam and do not warrant the billing of a separate problem-oriented E/M service,” Hinkle notes. However, “if a chronic condition is not being well controlled, and decisions are being made as to how to treat the patient to improve control (such as changing the dosage of medications or changing to a new medication), this may substantiate a separate problem-oriented E/M service,” Hinkle adds.

Recommendation 2: Document the Exam

This should cover height, weight, and body mass index (BMI), and an exam of the CPT^®-recognized organ systems (eyes; ear, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic/lymphatic/immunologic).

Recommendation 3: Document Screening Services

Again, depending on the patient’s age, your documentation should note any hearing, vision, developmental, and behavioral/ psychosocial screenings. As the child grows into adolescence, you should also document screenings for tobacco, alcohol, drug use, and depression.

Recommendation 4: Document Counseling/Anticipatory Guidance/Risk-Factor Reduction

Depending on the patient’s age, physical condition, and social and personal circumstances, the documentation should also show that your pediatrician addressed some or all of the following as appropriate:

• Behavioral issues, such as tobacco, alcohol and drug use; sexual activity and sexually transmitted disease avoidance; physical or sexual abuse; and problems with learning and school.
• Mental issues, such as depression and eating disorders.
• Physical issues, such as activity levels and injury prevention.
• Nutrition issues, such as limiting snacks and sugary drinks.

Recommendation 5: Document Vaccinations

According to the AAP, “every visit should be an opportunity to update and complete a child’s immunizations.” That means your provider should follow an immunization schedule such as the one published by the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. All vaccinations should be documented, and the vaccine along with the vaccine administration can be reported separately per CPT^® guidelines.

Remember: For any vaccine administration, you should also document consent. Additionally, when billing 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …), you will also need to document vaccine risk/benefit counseling by showing the patient has been given information such as the CDC provides in their vaccine information statements (VIS), which you can download at www.cdc.gov/vaccines/hcp/vis/current-vis.html.

Final Recommendations for Your Documentation

In the end, “the scope, and therefore the documentation, of a preventative visit depends both on the patient’s age and screening test(s) fitting the age and sex of the patient,” notes Walaszek.

This “should be based on the provider’s clinical judgment. For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended. What’s important is the documentation should very clearly show that all the elements of the annual preventive service were met,” Hinkle concludes.