Primary Care Coding Alert

Watch out for scenarios to report a problem visit on the same calendar date.

When reporting a preventive wellness visit, you will need to know what codes you have to report depending on the age of the patient and whether the patient is new or established. You should also learn about what other codes you can or cannot report with these wellness visit codes.

Choose Appropriate Code Depending on Age and Patient Status

When a patient comes to your office for a preventive wellness visit, choose from these CPT® codes depending on whether or not the patient is new (99381-99387) or established (99391-99397) and on the age of the patient:

• 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])
  
• 99382 (…early childhood [age 1 through 4 years])
  
• 99383 (…late childhood [age 5 through 11 years])
  
• 99384 (…adolescent [age 12 through 17 years])
  
• 99385 (…18-39 years)
  
• 99386 (…40-64 years)
  
• 99387 (…65 years and older)
  
• 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual… established patient; infant [age younger than 1 year])
  
• 99392 (…early childhood [age 1 through 4 years])
  
• 99393 (…late childhood [age 5 through 11 years])
  
• 99394 (…adolescent [age 12 through 17 years])
  
• 99395 (…18-39 years)
  
• 99396 (…40-64 years)
  
• 99397 (…65 years and older)
  

Example: Suppose a 36-year-old female patient comes to your FP for her annual preventive medicine visit. The patient is an established patient. You will have to report 99395 for the visit. In another instance, a new 17-year-old female patient sees your FP for an annual preventive medicine visit. You report this visit with 99384 as the patient is a new patient and is in the age bracket of 12-17 years.

Understand the Components of a Preventive Care Visit

When reporting a preventive care visit, you should be aware of all the components that are otherwise included in a code from 99381-99397. During the visit, the following components will typically be provided when you to report a preventive medicine code:

• An age and gender-appropriate history
• An age and gender-appropriate physical examination
• Counseling/anticipatory guidance/risk factor reduction interventions and
• The ordering of appropriate immunization(s), laboratory/diagnostic, and screening procedures

“According to CPT®, the ‘comprehensive’ nature of a preventive care visit is not the same as ‘comprehensive’ history or examination used in problem-oriented evaluation and management (E/M) codes like 99204, 99205, and 99215,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “For instance, the ‘comprehensive’ history portion of a preventive medicine visit does not include a chief complaint or history of present illness, since, by definition, the service is preventive and not intended to address an illness or injury of the patient.”

But it does involve your FP recording a comprehensive or interval past, family, and social history and a comprehensive assessment/history of pertinent risk factors. Per CPT® Assistant, the comprehensive examination performed as part of the preventive medicine service is multi-system, but the extent of the examination is based on the age and gender of the patient, and the risk factors identified.

Sometimes, an encounter may not be problem-oriented and may not involve a comprehensive age/gender-appropriate history and physical. If less than a comprehensive age/gender-appropriate history and physical exam is performed by your FP in those situations. CPT® Assistant advises that you report an appropriate level office or other outpatient E/M code for the visit.

Caveat: You should not report discussion of status of earlier diagnosed, stable conditions separately as this is a part of the preventive medicine code itself. Likewise, you should not additionally report any management of minor problems that your FP undertakes during the visit if they do not require additional work and the performance of the key components of a problem-oriented E/M service.

Don’t Report Counseling Services Separately

If you look at the components of the preventive care codes discussed above, you will see that it includes “counseling/anticipatory guidance/risk factor reduction interventions.” So, you cannot separately report these aspects with other CPT® codes in addition to reporting a preventive care code from the range 99381-99397.

“Preventive medicine counseling and risk factor reduction interventions will vary with age. For example, the counseling provided to a 13-year old patient will vary significantly from that provided to a 65-year old patient,” Moore observes. In the parlance of CPT®, “risk factor reduction interventions” are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment. “For example, counseling about diet and exercise is an entirely appropriate risk factor reduction intervention for an asymptomatic patient in a preventive medicine visit, even though it might otherwise be used as part of the treatment for a condition such as diabetes or obesity,” Moore adds. 

You can report the codes for preventive medicine counseling of an individual, 99401-99404, only if it is performed by your FP as a separate visit and not as a part of a preventive care visit. Also, you can report for counseling or risk factor reduction interventions separately when they are performed on the same day as a problem-oriented visit.

Know if Preventive Codes Can be Reported in Addition to Other E/M Codes

When a patient mentions a health problem or other concern during the preventive visit, you might be able to report aproblem-oriented E/M code for the evaluation and management of the problem in addition to reporting a preventive care visit code.

If the patient’s problem necessitated additional work required to perform the key components of a problem-oriented E/M service in addition to the preventive medicine visit, submit the appropriate preventive medicine code from 99381-99397 and the appropriate problem-oriented E/M code with 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) appended to the problem-oriented code.

If the problem required you to perform a procedural service, then you would submit the relevant procedure code, plus the appropriate preventive medicine code from 99381-99397 with modifier 25 appended to the preventive medicine code to indicate the preventive visit was significant and separately identifiable from the procedure (just as you would if billing a problem-oriented E/M code and an office procedure on the same date of service).

If you were reporting a preventive medicine E/M service, a problem-oriented E/M service, and a procedural service for the same encounter (a rare occurrence), you may need to append modifier 25 to both E/M codes to indicate that each is separately identifiable from the procedure and each other.