Primary Care Coding Alert

This FAQ on how to report 99381-99397 is exactly what the doctor ordered.

Recently, the Centers for Disease Control and Prevention (CDC) offered up a sobering statistic - that even though "preventive visits and vaccinations are just a few examples of ways people can stay healthy ... Americans use preventive services at about half the recommended rate." (Source: https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/PreventiveHealth.html)

Maybe your patients are not taking full advantage of the preventive services your provider offers on a continual basis. But that doesn't mean you shouldn't know the answers to the following frequently asked questions about preventive medicine evaluation and management (E/M).

So, read on, and become an expert in reporting this critical part of your practice's mission.

Question: What is a preventive medicine visit, and how is it documented?

Answer: Though the CPT^® guidelines note that "the extent and focus of the services will largely depend on the age of the patient," preventive medicine visits such as 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual ...) or 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) are comprised of the same basic elements, tailored to the age and gender of the patient:

• A "comprehensive" history;
• A "comprehensive" physical exam;
• Counseling, anticipatory guidance, and risk-factor reduction interventions (e.g. immunizations); and
• Ordering laboratory/diagnostic procedures.

As the guidelines preceding these codes in CPT^® note, the "comprehensive" nature of codes 99381-99397 reflects an age- and gender-appropriate history/exam and is not synonymous with the "comprehensive" examination required in E/M codes 99201-99350. Also,  some interventions, such as immunizations, are separately reportable.

Your provider's notes will need to document of the above. Additionally, as Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, points out, CPT^® guidelines require that "pre-existing problems and trivial problems or abnormalities encountered during the preventive medicine visit that do not require additional work should be noted but not reported."

Coding alert: The preventive medicine E/M codes are all age-specific, so make sure you assign the correct code for your patient.

Question: What kinds of screening, testing, and vaccinations are usually performed during a preventive visit?

Answer: Naturally, as Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, explains, "that will depend on the age and gender of the patient. What a provider screens, tests, and vaccinates for on a 6-month old female," Moore continues, "will be radically different from that for a 60-year old male. For example, the infant female could require testing for developmental delays and an IPV, inactivated poliovirus, vaccination, while the older male could require a prostate cancer screening and a vaccination for shingles."

A good place to find out what kinds of screenings, counseling, and vaccinations should be a part of a preventive medicine visit for older patients is this guide prepared by Medicare: https://www.medicare.gov/Pubs/pdf/10110.pdf.

Question: What happens if a preventive medicine E/M reveals a problem?

Answer: As Falbo noted previously, CPT^® guidelines are very specific about this: 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." However, should the visit uncover a significant problem, CPT^® directs you to report a problem oriented E/M service from 99201-99215, appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show that the service was distinct from the preventive medicine visit.

Question: What else can be reported separately from 99381/99397?

Answer: Any vaccines administered during the exam (as well as their administration) can be billed in addition to the preventive medicine codes providing they have a valid CPT^® or HCPCS code. So, for example, you can separately report and bill CPT^® codes for immunization administration and vaccine risk/benefit counseling such as90460 and+90461, codes for immunization administration without counseling (90471-+90474), vaccine/toxoid products such as90476-90749, hearing tests, and fecal occult blood tests.

However, as Moore points out, CPT^® guidelines do not allow you to separately report counseling and risk-factor reduction interventions such as 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual) or 99411-99412 (... in a group setting ...).

Question: Are preventive visits covered by insurance?

Answer: This is very much up to the individual payers. If they do cover preventive visits, they will often only allow one per year, and they may not cover all the services that such visits should entail. So, it is very important that you know exactly what your patient's health plan allows.