One E/M documentation challenge that medical coding outsourcing companies face is related to helping physicians report a preventive visit that becomes problem-oriented during the encounter. This is common in the primary care setting, when the patient presents for an annual preventive visit but suddenly brings up acute problems as well as questions about an existing or pre-existing problem. The challenge relates to how to code for the problem that the primary care physician addresses during the preventive medicine service.
Documenting and Coding Preventive Visits
Let’s first look at the documentation components required to code preventive visits. The CPT code set defines the annual preventive exam as a periodic, comprehensive preventive medicine evaluation (or reevaluation) and management of a patient. These services are represented by codes 99381-99397 and the code to report would be based on the patient’s age and whether the patient is receiving an initial (new patient) or a periodic (established patient) preventive service. Codes 99381-99397 are age-based, and distinguish between new and established patients:
- 99381 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; infant (age younger than 1 year)
- 99382 early childhood (age 1 through 4 years)
- 99383 late childhood (age 5 through 11 years)
- 99384 adolescent (age 12 through 17 years)
- 99385 18-39 years
- 99386 40-64 years
- 99387 65 years and older
- 99391 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; infant (age younger than 1 year)
- 99392 early childhood (age 1 through 4 years)
- 99393 late childhood (age 5 through 11 years)
- 99394 adolescent (age 12 through 17 years)
- 99395 18-39 years
- 99396 40-64 years
- 99397 65 years and older
AAFP lists the components needed when documenting preventive visits as follows:
- A comprehensive history and physical exam findings;
- A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT
- Notes about the management of minor problems that do not require additional work
- Notes related to age-appropriate counseling, screening labs, and tests
- Orders for vaccines appropriate for age and risk factors
CPT guidelines on coding for a “problem” that is addressed during a preventive medicine visit are as follows: “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E&M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier 25 should be added 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.”
In a report published in November 2017, the American Academy of Family Physicians (AAFP) points out that CPT does not define what qualifies as “insignificant or trivial” vs. “significant”. The AAFP recommends considering the following points when reporting a separate E/M service in addition to the preventive medicine service:
- Significant – Whether the presenting problem would have required a separate encounter
- Separately identifiable – Whether the E/M service requires the key components: history, exam and medical decision-making (MDM), or considerable counseling or coordinating care time
- Documentation – Whether there is additional documentation for the E/M service
When separate E/M reporting is supported
The AAFP provides examples of issues that can support separate E/M reporting as:
- A new condition that requires additional work such as strep throat or depression
- Worsening of a chronic condition (acne)
- New or changed prescription
- Required follow-up for certain conditions (e.g., asthma, attention-deficit/hyperactivity disorder)
When separate E/M reporting is not supported
An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported. According to the AAFP, the following are likely to be identified as incidental:
- Medication refill with no exacerbation
- Minor complaint or finding with very minimal work (e.g., mild diaper rash or mild upper respiratory infection) that may not have led the patient to come in for a separate appointment
- Chronic condition that is stable and not required to be addressed
Coding Tips
When both a sick visit and preventive visit are billed for the same patient on the same day using modifier 25, auditors will review the documentation to ensure that no portion of the exam and history for the preventive visit is used to support the level of the sick visit. Though services could overlap, CMS and CPT guidelines clearly state that both visits require separate documentation. The AAFP offers the following tips to code for a problem discovering during a preventive visit:
- Physicians should note that, unless billing based on time:
- History and medical decision making (MDM) are usually used to determine the E/M level, since more often, the exam falls under the “age appropriate exam” subsumed by the accompanying preventive medicine service.
- For new patient encounters, both codes may be billed as “new” patient status, though it will be necessary to meet the level for all three key components (history, exam and MDM) for the E/M service.
- Separate documentation will make it easier to identify the correct E/M code level.
- If billing based on time, only the time spent addressing the “problem” should be counted, and not the time spent on the preventive medicine service.
- A separate E/M office visit code is required when management of chronic conditions is needed or new problems are evaluated/treated.
One challenge to reporting preventive medicine services with an office visit to address a problem that the patient reports, is that the patient who receives both services will be hit with a copay for the sick visit. AAFP recommends establishing an office policy so patients are aware of their financial responsibilities.
Clinicians will reschedule the preventive service for a patient in a medical crisis. A Physicians Practice report recommends doing this for a patient with multiple problems to address, especially if there is no time to perform the annual exam and address the acute/chronic problems that the patient brings up. The most pressing concern can be treated and the rest could be rescheduled.
Reliable coders in reputable medical billing outsourcing companies will work with physicians to bill for E/M and preventive visits on the same date. Up to date on payer guidelines, they can help providers prevent denials with accurate codes and proper modifier use.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.