Internal Medicine Coding Alert

Reader Question:

Preventive and Problem-focused Coding

Published on Sun Jul 01, 2001

Question: If an internist performs a complete physical exam (CPE) on a 35-year-old male patient and the patient also presents with a chief complaint of a painful right thumb, would this still be coded as the CPE since 50 percent of the exam was preventive?

Wisconsin Subscriber

Answer: If the main focus of the exam was preventive, coders can use 99385 (initial preventive medicine, 18-39 years). If a significant problem is found for the thumb and the physician performs x-rays (73140, radiologic examination, finger[s], minimum of two views) or prescribes medication, an E/M office visit could be charged with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code.

If the problem is just being noted, you should not bill separately for it. According to CPT, if an abnormality/ies is encountered or a pre-existing problem is addressed during this preventive medicine E/M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that the same physician provided a significant, separately identifiable E/M service on the same day as the preventive medicine service.

An insignificant or trivial problem/abnormality that is encountered during the preventive medicine E/M service -- which does not require additional work and the performance of the key components of a problem-oriented E/M service -- should not be reported.

Medicare typically does not pay for preventive care, particularly the "annual physical," because it neglects to meet Medicare's definition of "medically necessary." However, if the above CPT guidelines are followed, Medicare pays for the problem and the patient pays for the noncovered preventive care service. As for commercial carriers, fees for both of these services may be reimbursed.

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