Primary Care Coding Alert

Look to medical associations for age- and gender-appropriate recommendations.

As important as the 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/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 …) preventive medicine evaluation and management (E/M) services are, CPT^® guidance for their use is surprisingly thin.

CPT^® tells you that “the extent and focus of the services will largely depend on the age of the patient.” But even that can create plenty of questions, which is why we’ve assembled plenty of answers below.

What Should Happen During a Preventive Medicine Service?

For this, you will need to go beyond CPT^® guidelines and look to recommendations formulated by medical associations. For primary care, that means looking to organizations such as “the AMA, the American Academy of Family Physicians, the American College of Physicians, and the American College of Obstetrics and Gynecology” for guidance, suggests Ellen Hinkle, BS, CPC, CDEO, CPMA, CRC, CEMC, CFPC, CGSC, CIMC, COBGC, CPCD, AAPC Approved-Instructor, provider compliance auditor at Bon Secours Mercy Health in Cincinnati.

For younger patients, that generally means looking to “the AAP [American Academy of Pediatrics] recommendations for preventive pediatric healthcare, which represent a consensus by the AAP and Bright Futures and are updated annually,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. The most current AAP periodicity schedule for pediatric preventive care can be found at downloads.aap.org/AAP/PDF/periodicity_schedule.pdf.

For adult patients, another great resource is the Adult Preventive Health Care Schedule, which is based on United States Preventive Services Task Force (USPSTF) recommendations that can be found at www.aafp.org/dam/AAFP/documents/journals/afp/USPSTFHealthCareSchedule2019.pdf.

What Should Be Documented in the History?

As the history should be age-appropriate per the code descriptors, it can range from documenting developmental milestones, such as walking and talking, for children; sleep and food habits for teenagers; and alcohol and drug use for older patients. As the history should also be gender-appropriate, it may also involve documenting such events as past pregnancies. Additionally, you can use the service to update information about surgeries and past and current illnesses.

“Simply noting the status of chronic conditions and refilling ongoing prescriptions is also expected during an annual preventive exam and typically do not warrant the billing of a separate problem-oriented E/M service,” Hinkle notes. However, “if a preexisting problem is addressed — for example a chronic condition that is not being well controlled — and decisions are being made as to how to treat the patient, such as changing the dosage of medications or changing to a new medication, this may substantiate a separate problem-oriented E/M service,” Hinkle adds.

In such situations, CPT^® guidelines advise that if the abnormality or preexisting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then you should also report the appropriate office/outpatient code from 99202-99205/99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …). Additionally, you should add 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 the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service.

What Should Be Documented in the Exam?

CPT^® guidelines note that the “‘comprehensive’ nature of the preventive medicine services … exam … is not synonymous with the ‘comprehensive’ examination required in evaluation and management codes 99202-99350.”

This means you don’t have to document all the same things you might otherwise have to document for a “comprehensive” exam in other E/M code families, and that you might even document things you otherwise wouldn’t in addition to the usual exam of CPT^®-recognized organ systems (eyes; ear, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic/lymphatic/ immunologic). In any case, as with history, the exam (and the elements included in it) should be age- and gender-appropriate.

What Screenings Should Be Documented?

Here, not only the patient’s age and gender but also the patient’s history will be determining factors in your provider’s decision to screen. For younger patients, your documentation should note any hearing, vision, developmental, and behavioral/psychosocial screenings when performed. Screenings for tobacco, alcohol, drug use, and depression would also be appropriate for adult patients.

“The provider’s clinical judgment will come into play here. For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended,” Hinkle suggests.

How Should Counseling/Anticipatory Guidance/Risk-Factor Reduction Be Documented?

Here, you should make sure that your documentation indicates your provider addressed any behavioral, mental, physical, and nutrition issues that could be affecting the patient’s health. In addition to age, gender, and history, the discussion should also take into account the patient’s social and personal circumstances, so the note should contain any mention of sexual activity and sexually transmitted disease avoidance, physical or sexual abuse, problems with learning and school for younger patients, family problems, substance use, dental health, depression, activity levels and injury prevention, and eating disorders and nutritional counseling.

What Vaccinations Should Be Documented?

According to the AAP, “every visit should be an opportunity to update and complete a child’s immunizations.” That is also true for adults and means your provider should be following an immunization schedule such as the ones recommended by the Centers for Disease Control and Prevention (CDC) for children (at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf) and adults (at www.cdc.gov/vaccines/schedules/hcp/imz/adult.html).

When appropriate, you should also document patient consent and any vaccine risk/benefit counseling that your physician has offered such as the information the CDC provides in their vaccine information statements (VIS), which you can download from www.cdc.gov/vaccines/hcp/vis/current-vis.html.

Coding alert: Remember, vaccine administration is a separately reportable service, and you should report it with 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …) when it involves counseling and 90471/+90472/90473/+90474 (Immunization administration …) when it does not.

Final Recommendations for Your Documentation

In the end, “the scope, and therefore the documentation, of a preventive visit depends both on the patient’s age and gender and on screening test(s) fitting the age and sex of the patient,” Walaszek concludes.

“What’s important is the documentation should very clearly show that all the elements of the annual preventive service were met,” Hinkle adds.