An Ounce of Prevention When Coding Preventive E&M Services

February 27th, 2015 / By Rebecca Caux-Harry

In previous blogs, I’ve written in detail about the different sets of exam guidelines, scoring of HPI, ROS, MDM and other details. These are the components that make up the supporting documentation for most E&M services.  There are a few exceptions, however, like critical care, facility coding, and preventive medicine.

There are many types of E&M visits, primarily separated into sick versus well visits. They can occur at the same time, but usually don’t.  Patients coming in for their annual physical usually schedule another visit to discuss any acute issues. In the circumstance when a provider provides both services during the same visit, documentation needs to be very clear that two services were provided during the same visit. Patients often don’t understand that the annual physical doesn’t include any/all other issues and can be surprised when two charges are submitted to their insurance payer.  They can also be surprised by a co-pay for a service they think should be covered as screening with no co-pay.  A thoughtful discussion with the patient at the time of check-out is a good way to avoid an unhappy patient after the fact.

If submitting two E&M services on the same day (as in this example), a well and sick visit, a -25 modifier on the sick visit will tell the payer that two distinct services were provided. Whether they recognize the modifier and pay both is another matter.  Scoring of this type of visit needs to be very clear as well.  Ideally, the provider will create two separate notes, one for each E&M code, but I’ve rarely found the “ideal” when it comes to E&M documentation.  Because documentation requirements for the well visit, or Preventive Medicine Service, are not specifically outlined, it can be difficult to determine what is included in the well visit and what portion of the service goes beyond that.

CPT codes for well visits are based on patient age and on new versus established status. Per CPT descriptors of the Preventive Medicine codes, both new and established (periodic) visits are comprehensive in nature.  This assessment is to be guided by the patient’s age and gender and to include an appropriate comprehensive history, exam, counseling and discussion of risk factor reduction.  It also includes any ordering of labs or diagnostic testing.  The codes, new patient, 99381-99387, and established patient, 99391-99397, are based on patient age only.

If submitting an additional sick E&M code, the argument can be made that this code would always be a lower level code. Documentation used to support the preventive visit can NOT be used to support the sick visit.  So keeping in mind that the preventive visit includes a comprehensive history and exam, there would be little left over to count toward the documentation requirements of a sick visit.  Additionally, because of the requirements of new patient sick visit codes, 99201-99205, the occurrence of a new patient preventive and sick visit in the same day would likely never happen.  The patient can only be new if not seen by the provider, or partner of the same specialty, for three years.  So, the patient is either new for the preventive visit, or new for the sick visit, but not both.

So tread carefully when submitting these two types of services together. Make sure the documentation supports both the comprehensive preventive exam and the most likely low level sick exam.  Make sure to append the -25 modifier to the sick visit code, and it’s always a good idea to inform the patient about the coding/billing for those services.

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.