EM Coding Alert

Question: Our providers perform many preventive care services like physicals and wellness exams, and for about half of these, they want to charge for a problem-focused visit as well. What are the criteria for meeting the documentation requirements of billing a preventive care service with a problem-focused visit?

Rhode Island Subscriber

Answer: You may be able to report a problem-oriented E/M in addition to a scheduled preventive care visit when a patient comes in for a visit such as an annual exam, Pap test, or screening mammogram and mentions a specific healthcare problem or other concern. According to CPT^® 2017, to qualify, the problem must be significant enough to require the additional work of a problem-oriented E/M service.

You should always code for the preventive service first. Choose from 99381-99387 (Initial comprehensive preventive medicine evaluation and management …)  for new patients or 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management …) for established patients.

Remember: The documentation must separately support the history, exam, and medical decision making (HEM) for both the preventive service and the problem-oriented code. The notes do not have to be separate, but the delineation between the two must be clear.

For your next step, reporting the problem-oriented visit, choose among 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) for new patients and 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) for established patients. 

Important: You must append 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 show that the physician performed two separate services. The diagnosis code for the E/M service should not be that of a general health examination but, rather support the concern addressed during that portion of the visit.