Primary Care Coding Alert

Question: Can I report the preventive medicine counseling codes with problem-oriented evaluation and management (E/M) codes?

New York Subscriber

Answer: Yes, you may report codes 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15/30/45/60 minutes) in addition to 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires a medically appropriate history and/or examination and straightforward/ low/moderate/high medical decision making...) where appropriate, but it will likely require 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).

Why? Take a look at the CPT^® guidelines that precede 99401-99404, which state: “These codes are used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed.”

Example: Let’s say an established patient presents with an acute upper respiratory infection, which the primary care practitioner (PCP) diagnoses and treats. During the encounter, the patient inquires about losing weight, which leads the PCP to spend 15 minutes discussing things the patient can do, such as diet and exercise, that may be helpful. In this case, per CPT^®, it would be appropriate to report 99401 in addition to the appropriate level of problem-oriented E/M service, with modifier 25 appended to the problem-oriented E/M code. The preventive medicine counseling is not bundled with the 99202-99215 codes and is separate from the presenting problem. Be sure the documentation makes these things clear. The payer will want to see separate notes for each service, and clear statements of how the services were unrelated.