Primary Care Coding Alert

Question: The CPT® description of initial and periodic comprehensive preventive medicine services states: 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.

Is documentation of the counseling/anticipatory guidance/risk factor reduction counseling a required element of a preventive medicine E/M? If the physician does not document any counseling, etc., is it appropriate to still assign a preventive medicine services E/M 99381-99397?

Illinois Subscriber

Answer: You can report 99381-99397 without documentation of the counseling/anticipatory guidance/risk factor reduction, if it had not taken place. 

The guidelines preceding these codes in CPT® state that they “include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.” However, nothing in CPT® states that such counseling is a required element of the codes.

As noted, the descriptor for these codes refers to them as “comprehensive.” This leads some people to assume that the service must include a comprehensive history and examination like those associated with problem-oriented E/M codes. However, that is not the case. The same CPT®  guidelines preceding codes 99381-99397 also state, “The ‘comprehensive’ nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the “comprehensive” examination required in Evaluation and Management codes 99201-99350.”

Coding tip: Depending on the age of the patient, you report from CPT® codes, 99381-99387 (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…)for a new patient. If the patient is established, choose from codes, 99391-99397 (Periodic comprehensive preventive medicine 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, established patient…)again based on age of the patient.