Primary Care Coding Alert

Question: I am new to coding and confused about the distinctions between a preventive services code and an evaluation and management code. Also, what is meant by split bill?

Diane Cleveland
Medical Arts Clinic, Rapid City, S.D.

Answer: CPT guidelines state that preventive medicine codes 99381-99397 describe encounters with patients who are presenting for reasons that generally do not include diagnosis or treatment of a symptom or illness (although these may be addressed during the course of an encounter as discussed below). Evaluation and management (E/M) codes 99201-99215 are assigned to new or established patients when they are seen for a problem-oriented exam that may include taking a history and making medical decisions about treatment for the patients condition.

Initial and periodic preventive evaluations include a comprehensive history and comprehensive physical exam in addition to counseling and risk-factor reduction advisement. Coders should recognize that the history and exam portions of the preventive service do not directly coincide with the requirements of other E/M services. Different levels of E/M services are distinguished by the complexity of the exam and the time devoted to it. But preventive services are based on exams that are appropriate for the patients age and identified risk factors. For instance, CPT code 99381 is assigned when preventive services are provided to a new infant patient, while 99384 would be assigned to a new adolescent patient. Preventive services do not include immunizations, or laboratory or radiological services.

CPT guidelines indicate that when the physician encounters an abnormality or pre-existing condition that is significant enough to require additional work to perform the key components of a problem-oriented E/M service during a preventive visit, an E/M visit may be reported in addition to the preventive service. The E/M code should be reported with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Split bill is the term commonly used to describe instances when both a preventive service visit and an E/M code with modifier -25 are reported.

For example, a 45-year-old woman makes an appointment for a preventive visit. During the checkup, the patient complains of lethargy and increased thirst during the past few months. Concerned that she may be developing diabetes, the physician focuses part of his examination on these symptoms and orders appropriate lab work. This encounter would be coded as a split bill: 99396 (established patient, periodic preventive medicine, 40-64 years) would be assigned with the appropriate level of E/M visit for an established patient (e.g., 99212 or 99213). The E/M code would be assigned with the -25 modifier.

Many coding experts believe that practices lose a lot of revenue by not using the split-bill approach. Patients may schedule a physical but often use that as a way to bring specific problems or concerns to their physicians attention. Clinical practitioners need to clearly document occasions when a preventive visit includes E/M services so coders can report complete charges for reimbursement.

Coders should recognize that payment ultimately depends on carrier policy. Many commercial carriers may recognize only one code or the other. In these instances, the physician should choose the code that represents the focus of the majority of the visit.

Medicare does allow payment for the problem-oriented service at the time of the preventive visit. It will pay for the problem-oriented service. The physician is allowed to bill the difference between Medicares allowed fee and the preventive service fee to the patient. This way, when the patient and Medicare pay, the physician has received the total fee for his preventive service, but no more.