Internal Medicine Coding Alert

Level of documentation important to decide additional E/M code

When you encounter your internal medicine provider performing evaluation of a problem during a preventive annual checkup, you will need to know under what circumstances a problem-oriented E/M code can be reported separately for this service. Also, you will need to know whether or not you are allowed to report a counseling service separately in addition to a preventive medicine code.

Here are two case scenarios that will help you understand when you can report an additional E/M service code along with a preventive medicine code and also if you are permitted to report counseling codes with preventive medicine codes.

Case Scenario 1:  Your internist sees a 50-year-old new male patient for an annual check up. During the checkup, the patient queries your physician about some darkening of the skin in the area of the arms and armpits. Your clinician notes these changes and performs an examination of the area and decides that the changes are nothing significant and attributes it to aging. The patient also has concerns about his obesity and your clinician counsels the patient regarding diet changes to help reduce weight and fight obesity.

In this case scenario, can a problem-oriented E/M service be reported in addition to the preventive medicine code, since your clinician performed an extra service to check and examine the area of discoloration? Also, can an additional counseling code be reported for the service provided by your clinician towards reducing weight?

Case Scenario 2: Your internist sees a 39-year-old established male patient for an annual check up. During the checkup, your physician notes that the patient is persistently coughing. When queried by your clinician, the patient says that he has been having this persistent productive cough for the past week or so and it has been fluctuating in intensity. Your clinician performs a detailed examination of the respiratory and cardiovascular systems. Based on the history, signs and symptoms, and observations during examination, your clinician arrives at the diagnosis of acute bronchitis. He prescribes medication for the problem and calls for a review after a week. He also completes the other aspects of the annual checkup.

So, can a problem-oriented E/M service be reported in addition to the preventive medicine code for the examination of the patient for the problem or should only the preventive medicine code or a problem-oriented E/M code be reported for the visit?

Check If You Can Report Other E/M Codes With Preventive Codes

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) to your practice or established (99391-99397) and on the age of the patient. For instance, if your internist is seeing a 25-year-old new patient, you will report the wellness visit with 99385 (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; 18-39 years) while you will report 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual…established patient; 18-39 years) for an established patient in the same age group.

When a patient mentions a health problem or other concern during the preventive visit, you might be able to report another E/M code for the evaluation and management of the problem in addition to reporting a preventive care visit code.

“CPT^® guidelines preceding the preventive visit codes state that if an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive medicine E/M service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported,” notes a coding consultant. “Conversely, CPT^® says that an insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E/M service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”

“One way to determine whether the abnormality or problem is ‘significant’ or ‘insignificant/trivial’ is to look at the documentation of that abnormality or problem,” the expert observes. “If that documentation on its own and apart from the preventive medicine documentation would support reporting a problem-oriented E/M code, then the abnormality or problem may be significant enough to do so,” he adds.

If the patient’s problem necessitated additional work required to perform the key components of a problem-oriented E/M service in addition to the preventive medicine visit, submit the appropriate preventive medicine code from 99381-99397 and the appropriate problem-oriented E/M code with 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) appended to the problem-oriented code.

In case scenario 1, your physician did not take any history pertinent to the problem, so he did not perform the additional work necessary to perform all the key components of a new patient office visit. Additionally, it could be argued that the internist did not find any significant problems, since he did not order any subsequent treatment. For these reasons, you should not report the problem of discoloration that your provider reviewed with an additional E/M code. So, you will only report the preventive medicine codes in this case which will be 99396 (…40-64 years) as the patient is an established patient and is in the age group between 40-64 years.

“In scenario 1, it’s clear that the physician did some examination related to the patient’s complaint about the skin discoloration,” the coder says. “If this was an established patient and the documentation supported that the internal medicine specialist also went through a medical decision making process to determine that this was simply a sign of aging and required no treatment and follow-up, then reporting a problem-oriented E/M code in addition to the preventive medicine service might be supportable, at least at a low level. However, the provider may still judge the ‘problem’ to be so slight as to not merit an additional E/M code. Remember: sometimes determining that something does not require treatment or follow-up may still require medical decision making to arrive at that conclusion,” he suggests.

In case scenario 2, your internal medicine provider uncovered that the patient had a persistent cough. He then performed a detailed examination of the respiratory and cardiovascular systems. He made the diagnosis of acute bronchitis and prescribed medication for the same. Since the patient had a problem that your clinician evaluated and managed, you will have to report an additional E/M such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient…) as the patient is established. You will have to append modifier 25 to the E/M code that you are reporting. You will report the annual checkup with the CPT^® code, 99395 as the patient is established and in the age group between 18-39 years.

Don’t Forget to Assign Proper Diagnosis Codes

When you are reporting a problem-oriented E/M service in addition to a preventive medicine code, you will have to report separate diagnosis codes for the preventive medicine code and the other E/M service. If you do not support the E/M service with appropriate diagnosis codes along with required documentation, your claim for the E/M service will be rejected.

So, in case scenario 1, you will report Z00.00 (Encounter for general adult medical examination without abnormal findings) to support the preventive medicine code that you are reporting. In case scenario 2, you will have to report Z00.01 (Encounter for general adult medical examination with abnormal findings) to support the preventive medicine code that you are reporting. “Since ICD-10 advises you to use an additional code to identify the abnormal findings, you will also append J20.9 (Acute bronchitis, unspecified) to the preventive medicine code after Z00.01,” observes a coding expert. In addition, you will have to report J20.9 with the problem-oriented E/M code for the scenario.

Understand if You Can Report Counseling Services Separately

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 aspects with other CPT^® codes in addition to reporting a preventive care code from the range 99381-99397.

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. Also, you can report for counseling or risk factor reduction interventions separately when they are performed on the same day as a problem-oriented visit.

So, in case scenario 1, you cannot report the diet counseling performed by your internist with a separate CPT^® code from the range 99401-99404 in addition to reporting 99396.

---