Internal Medicine Coding Alert

Question: How can I tell if a problem that the internist diagnoses at a preventive medicine visit is considered significant?

California Subscriber

Answer: If the problem or abnormality is significant, you should code the appropriate E/M visit (such as 99201-99215, Office or other outpatient services) in addition to 99381-99387 or 99391-99397 (Preventive medicine services). In these instances, you use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the sick visit code to indicate the problem is significant and separately identifiable from the preventive medicine service.
If the problem is not significant, you should report only 99381-99387 or 99391-99397.

You should consider a problem significant if you can answer "yes" to these items:

• the problem would require a return visit

• a prescription is required

• a significant amount of distinct time is devoted for counseling and coordination of care for the distinct and separately identifiable abnormality/ies or preexisting problem and is formally addressed in the process of performing the preventive medicine evaluation and management.

• there is a separate supporting ICD-9 diagnosis

• there is separately recorded documentation for the problem that includes the key components of a problem- oriented evaluation and management service.