Clarification:
Office Visits and Preventive Medicine Coding Continued
Published on Sun Feb 01, 1998
In the January 1998 issue, we covered the question of whether you can code a physical as an office visit. The answer is no. The article focused on the problem that arises when a patients insurance plan doesnt cover well visits, and a pediatric office might feel tempted to code it as an office visit. Again, the clear answer is: dont do it.
However, part of the article discussed the use of a preventive medicine code and an office visit code at the same time. Victoria S. Jackson, administrator and CEO for Southern Orange County Pediatric Associates in Lake Forest, CA, stated in the article that you cant use both codes at once. Theyll downcode you to the lowest code anyway, she said.
In fact, CPT coding does allow for both codes to be used, providing that a significant problem is discovered during a preventive visit. You would do this using the modifier 25.
From the CPT manual under Preventive Medicine Services:
If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management 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, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier `-25' should be added to the Office/Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine Evaluation and Management 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.
Jackson also said in Januarys issue youre not going to get paid for finding an earache during a well visit. But that doesnt mean you cant use both codes. It all depends on how significant the problem is that you discover during the well visit.
If you spend additional time over and above the time usually spent in the preventive care part of the exam because of a problem, then you most definitely can code both services, says Charles A. Scott, MD, FAAP, who practices in Medford, NJ. As an example, Scott, a regional coding resource for the AAP, cites the hypothetical case of a three-year-old who comes in for a check-up. During the visit you see that the child is having a moderate amount of wheezing requiring a nebulizer treatment as well as listening to [...]
