Question: Our physician often does counseling and provides anticipatory guidance for risk factor reduction. Can we report a preventive medicine E/M for this counseling? Is this counseling a mandate for the preventive medicine E/M coding? If the physician does not document any counseling or any such services, is it appropriate to still assign a preventive medicine services E/M 99381-99397?
Illinois Subscriber
Answer: You can report 99381 (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; infant [age younger than 1 year]) through 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…) without documentation of the counseling/anticipatory guidance/risk factor reduction, if it had not taken place.
The CPT® description of initial and periodic comprehensive preventive medicine services states: 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.
This means codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination. However, CPT® states nowhere that such counseling is a required element of the codes.
Watch for the term ‘comprehensive’: As noted, the descriptor for these codes refers to them as “comprehensive.” This leads some people to assume that the service must include a comprehensive history and examination like those associated with problem-oriented E/M codes. However, that is not the case. The same CPT® guidelines preceding codes 99381-99397 also state, “The ‘comprehensive’ nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the “comprehensive” examination required in Evaluation and Management codes 99201-99350.”
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 (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; infant [age younger than 1 year]) - 99397 again based on age of the patient.
When a preventive visit is provided to the patient, it should encompass the required criteria including discussion of risks and anticipatory guidance if provided. Many insurance carriers will only allow one preventive service annually. Therefore, it is possible the patient could have already completed their comprehensive physical visit service with their primary care practitioner. While risks and anticipatory guidance is part of a preventive services, if counseling is performed with a problem focused visit regarding their disease and further prevention of prevention or reoccurrence it may be considered much different from the comprehensive topics discussed at an annual physical visit. It is important the physician understands the difference so their documentation can reflect the discussion most accurately.
