EM Coding Alert

Question: A 50-year-old new male patient with a strong family history of cancer reported to our physician for an annual checkup. During the visit, the patient expressed concern to our physician about few patches of darkening of the skin in the area of the arms and armpits. Our physician made a note of these changes and, after a brief examination of the area, decided that the changes were insignificant and attributed them to aging. The patient also has concerns about his obesity and how this could increase his risk of cancers, and our physician advised the patient regarding diet changes to help reduce weight and fight obesity.

How can we report this preventive service visit? Is it correct to report a problem-oriented E/M service in addition to the preventive service since our physician performed an extra service to check and examine the area of discoloration? Also, can we report the counseling for dietary changes and weight management that our physician did?

Connecticut Subscriber

Answer: When a patient comes to your office for an annual checkup, you will typically report from one of these CPT^® codes depending on whether or not the patient is new (99381- 99387) or established (99391-99397) to your practice and based upon the age of the patient.

You should submit the preventive medicine code 99386 (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; 40-64 years) for the scenario described.

Additional E/M code may not apply: Your physician has documented a family history of cancer but did not need to take any history pertinent to the skin discoloration problem. Hence one may conclude that your physician did not perform the additional work necessary to perform all the key components of a new patient office visit. Additionally, the provider discovered no significant problems, nor did the provider order any subsequent investigations or treatment. For these reasons, you should not report the problem of discoloration that your provider reviewed with an additional E/M code.

Counseling for weight management: If you look at the components of preventive care codes, you will see that it includes “counseling/anticipatory guidance/ risk factor reduction interventions.” So, you cannot separately report these services using other CPT^® codes in addition to reporting a preventive care code from the range 99381-99397. This means you cannot report the diet counseling performed by your physician with a separate CPT^® code from the range 99401-99404 in addition to reporting 99396.

You can report the codes for preventive medicine counseling, 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]...) for individual counseling only if it is performed by your provider as a separate visit and not as a part of a preventive care visit. It can also be reported where counseling or risk factor reduction interventions are rendered and noted as a separate code when they are performed on the same day as a problem-oriented visit.

Diagnosis code: Do not forget to submit ICD-10-CM code Z00.00 (Encounter for general adult medical examination without abnormal findings) to support the preventive examination service that you are reporting. If the visit had included abnormal findings, you would look to Z00.01 (Encounter for general adult medical examination with abnormal findings) with an additional code to identify the abnormal finding(s).