Internal Medicine Coding Alert

Question: The CPT® description of initial and periodic comprehensive preventive medicine services states: evaluation and management of a individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory /diagnostic procedures.

Is documentation of the counseling/anticipatory guidance/risk factor reduction counseling a required element of a preventive medicine E/M? If the physician does not document any counseling, etc. is it appropriate to still assign a preventive medicine services E/M 99381-99397?

Chicago Subscriber

Answer: No, you can report 99381-99397 without documentation of the counseling/anticipatory guidance/risk factor reduction, if it had not taken place. 

A Preventive medicine visit will include the following: 

• Comprehensive history including 
• Complete review of systems 
• Complete past, family and social history 
• Comprehensive assessment/history of pertinent risk factors 
• Multisystem examination appropriate to the patient’s age, gender and indentified risk factors 
• Documentation of any recommendations or findings

Coding tip: Depending on the age of the patient, you report from CPT® codes, 99381-99387 (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…) for a new patient. If the patient is established, choose from codes, 99391-99397 (Periodic comprehensive preventive medicine 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, established patient…) again based on age of the patient.