EM Coding Alert

Question: Do I need to use a modifier when billing 87491 with an annual wellness visit?

Maine Subscriber.

Answer: Per National Correct Coding Initiative (NCCI) edits for the preventive medicine codes 99381-99397 (Initial/periodic comprehensive preventive medicine evaluation/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, new/established patient …), 87491 (Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique) is not a column 2 code for any of the preventive medicine visits. The same is true for 87491 and the Medicare annual wellness visit codes, G0438 and G0439.

This is echoed by CPT^® guidelines preceding codes 99381-99397, which tell you that “vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg, vision, hearing, developmental) identified with a specific CPT^® code are reported separately.”

Consequently, as the two codes are not regarded as an edit pair and can be reported separately, a modifier is not needed to separate the services.