EM Coding Alert

Beware: Coding preventive medicine encounters as problem visits is a problem.

When a preventive care service and an illness are presented in one visit, coding for that combination visit can be tricky — and getting payment can be even trickier. 

Find out how you can overcome the challenges of coding preventive and problem-oriented encounters with this expert advice. 

Code the Preventive Service First

A combination visit occurs when a new or established patient comes in to your physician’s office for a preventive encounter and an issue is found.

Preventive services are health care services started early to prevent illness or detect illness at an early stage. Some examples include annual exams, Pap tests, flu shots, and screening mammograms.

When your physician sees a patient for a preventive visit, but during the encounter he also performs history, exam, and medical decision making for a problem the patient has, you should report both the preventive encounter code and the problem-oriented encounter code. 

Report the preventive medicine service first, either from the 99381-99387 (Initial comprehensive preventive medicine evaluation and management…) range for new patients or the 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management…) range for established patients. Then, report the problem-oriented office visit from the new patient range 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient…) or established patient range 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient…). You will need to attach 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) to the problem-oriented office visit to make it clear that there were two separate services.

Example: A 47-year-old new patient comes in to the office for her yearly preventive exam. During the encounter, the patient states that she recently cut her finger and thinks it is infected. The provider performs a detailed history about the cut and performs a detailed exam. He determines that the cut is indeed inflamed and infected. He prescribes an antibiotic and takes a culture to test for Methicillin-Resistant Staphylococcus Aureus (MRSA).

You would code the preventive exam with 99386. You can also report the problem with 99203 with modifier 25 attached, based on the problem-oriented detailed history and exam and low complexity medical decision making. Without modifier 25, you take the chance of not being paid for the problem-oriented portion of the encounter along with the preventive service. 

Nail Down Ways to Be Reimbursed

According to some experts, Medicare may follow suit with other payers when it comes to covering preventive medicine visits. “Most payers cover at least one preventive medicine visit annually,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. 

“Even Medicare is moving in that direction with the Initial Preventive Physical Examination (IPPE) and annual wellness visits.” Because most payers do pay for preventive care, the more you know about what you can do to punch up your claim, the better your chances are of getting paid.

The keys to preventing non-payment of claims in this situation are documentation, correct coding, and knowing what the payer’s policy is, according to Moore. Here are five tips to make your claim stronger:

• Append the modifier 25 on the problem-oriented office visit.
• Ensure the ICD-9 code you assign supports the medical necessity for the services.
• Document the preventive care and the office visit separately.
• Know what preventive services your payer contracts cover.
• Appeal if you receive an unwarranted denial. 

Experts warn: Make your physicians aware that trying to help their patients avoid out-of-pocket costs by documenting preventive services as problems is fraudulent and could cost them dearly.