Wiki well visit&E&M codes

[snelson421]

Looking for input reguarding 2 scenarios
1. pt comes in for yearly preventive screening exam and presents with new problem requiring work up (such as labs or medication) The physician bills the preventive service, can she also bill an appropriate E&M code for the new problem or is it included in the preventive exam?

2. pt comes in for yearly preventive screening exam adn has a history of hypertension. BP is not controlled on current meds adn requires modificarion. The physician bills the preventive service. Can the physician also bill an appropriate level E&M code for the treatment of hypertension?

Thanks

 

[JDACPC]

From the research I have done on this, you can bill the "problem visit" separately but you have to follow the 25 modifier guidelines. I have actually taken the preventative visit note, crossed out everything required for that code and had to determine if there was enough "Significant, Separately Identifiable Evaluation and Management Service" documented to bill the problem visit. You will append the 25 modifier to the office visit code, not the preventative visit.

In both your examples, in my opinion, you could bill both codes IF there is enough documentation to support BOTH services.

Be sure you link your diagnoses to the proper code. V code for the preventative, and the dx for the problem visit must be linked to the office visit. And as usual, some carriers will never pay both on the same day.

 

[snelson421]

Thanks for your input!!

 

[MikeEnos]

CPT Assistant highlights two examples very similar to what you've described above - and they use it to illustrate instances of when it is appropriate to bill for a routine preventive visit AND an office evaluation and management service on the same day. Here I'll paste it for you:

CPT Assistant:

Family Practice and Internal Medicine
A 55-year-old established male patient presents to the
physician's office for periodic preventive medicine
reevaluation and management. The patient has
established diagnoses of hypertension, on beta blocker
therapy, Type II diabetes controlled with sulfonylurea,
and chronic stable angina controlled with sublingual
nitroglycerin as needed.

A comprehensive history and examination are
performed as part of the preventive medicine service.
Furthermore, a specific history is taken and further
examination is performed regarding the established
diagnoses as listed above.

To report this, CPT code 99396 would be used for the
preventive medicine services visit. In addition, the
appropriate problem oriented level of E/M service would
be selected based on the key components associated
with providing the problem oriented E/M service.

CPT Assistant

Pediatrics and Family Practice
A woman brings her 3-year-old son, established patient, to
the physician's office for annual health supervision and
evaluation. During the preventive medicine encounter, the
physician notes inflammation of the right middle ear. Upon
further questioning, the mother recalls a two day history of the
child pulling at his right ear. He has been irritable, running a
low grade fever, coughing, and has had difficulty sleeping at
night. The physician then (additionally) performed the key
components of a problem-oriented evaluation and
management service.

Appropriate laboratory tests were ordered. Antibiotics were
prescribed and a follow-up visit was scheduled. The
physician diagnosed acute right otitis media, acute tonsillitis,
and acute adenoiditis.

To report this, CPT code 99392 would be used for the
preventive medicine services visit. In addition, the
appropriate problem oriented level of E/M service should
be selected based on the key components associated
with providing the problem oriented E/M service.

Here's an excerpt from the CPT E/M Section Guidelines

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 the evolution and management (E/M) codes 99201-99350. Codes
99381-99397 include counseling/anticipatory guidance/risk
factor reduction interventions provided at the time of the
initial comprehensive preventive medicine examination or
periodic re-evaluation. (Codes 99401-99412 are used for
reporting counseling/anticipatory guidance/risk factor reduction interventions provided separately from the preventive
medicine examination.)

If an E/M service code (99201-99350) is reported in addition to a code from the 99381-99397 and/or 99401-99412
series, modifier 25, Significant, separately identifiable E/M by
the same physician on the same day of the procedure or other
service, should be appended to the appropriate level E/M
service code. Modifier 25 is reported to indicate that on
the day a procedure or service identified by a CPT code was
performed, the patient's condition required a significant and
separately identifiable E/M service above and beyond the
other service provided. A significant, separately identifiable
E/M service is defined and/or substantiated by documentation that satisfies the relevant criteria for the respective E/M
service to be reported.