Primary Care Coding Alert

Although there are many instances in which using preventive-medicine codes are the correct option when billing for routine exams of diabetic patients, in most cases it is not correct.

For example, some practices might use the periodic preventive-medicine reevaluation and management code 99395 (18-39 years, established patient) for bimonthly visits to a family doctor by a 25-year-old female patient with diabetes who has her glucose level and blood pressure monitored and her feet and eyes examined, but thats not the case.

Randy Thompson, CPC, a senior consultant in Nashville, TN with HealthCare Consultants of America, a medical management firm specializing in fraud, abuse, coding and billing, reminds coders that preventive- medicine services (99381-99397) only apply to routine physicals without a relationship to a specific illness and can only be used when neither the history nor examin-ation has any relationship to a presenting problem or chronic condition.

A periodic preventive-medicine re-evaluation and management of an individual includes a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures.

A preventive-care code requires a comprehensive history and assumes the patient is asymptomatic, says Pat Skeens, training specialist at Indiana University School of Medicine, Compliance Office in Indianapolis. The visit for diabetes maintenance is a follow-up exam, not a preventive treatment so it should be coded as an office visitE/M codesdepending on the level
of care.

1. Use established patient codes: The appropriate E/M codes are office or other outpatient services for an established patient, which can be coded at different levels (99211-99215) depending on the complexity of the history, examination and medical decision-making. They range from a simple visit not requiring the services of a physician to a comprehensive history and examination with medical decision-making of high complexity.

Consider a diabetic female patient who visits her family physician regularly for her chronic disease but is generally feeling well. The history is problem-focused: She is seeing the family doctor as a follow-up for her diabetes, which is under control. She does not require an examination, and medical decision-making is straightforwardone stable chronic illness with minimal risk.

She continues on the same dose of insulin and plans to return in two months. Thompson says that this would be coded 99212 (office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making).

2. Coding for complications: On the other hand, the same 25-year-old female diabetic sees her family practitioner as she does monthly, but during this visit she also complains of a sore throat. Now the history is expanded problem-focused since she has had the scratchy throat for three days due to a weekend camping trip.

The examination is detailed because it entails an extended analysis of an affected body area/system and other symptomatic or related organ systems, specifically to test for strep throat. Although the number of diagnoses and management options increase (because the problem is new and requires a work-up), making the decision-making of high complexity, the amount and/or complexity of data to be reviewed and the risk of complications are only moderate; thus, decision-making is of moderate comp-lexity (to qualify for a given type of decision-making, two of the three elements must be met or exceeded).

This visit would be coded 99214 (office or outpatient visit for the evaluation and management of an established patient which requires at least two of these three key components: a detailed history, detailed examination, and medical decision-making of moderate complexity). Thompson explains that the diabetes in conjunction with the sore throat has pushed the office visit up to level 4.