Preventive Medicine Versus E&M Codes: The Same-Day Coding Dilemma

Choosing a proper office visit code can become confusing unless one understands the rules separating preventive medicine and evaluation and management (E&M) coding.

Problem-oriented E&M services, office, and other outpatient visit codes 99202-99215 (along with hospital, observation, and consultative encounters) are for patients who present with signs, symptoms, conditions, diagnoses and/or problems that need to be “addressed” by a physician or qualified healthcare professional, and the reason for the encounter is usually documented using the patient’s own words.

Preventive medicine codes are meant for the reporting of asymptomatic patients, for risk factor reduction, and to establish care and services; these are largely dependent on the age of the patient. In order to assign a preventive code, a comprehensive evaluation must be documented. The scope of a preventive visit depends both on the patient’s age and screening test(s) fitting the age of the patient.

Medicare does not cover CPT® codes 99381-99397 (preventive medicine services). When billing a preventive medicine visit for a Medicare patient, a waiver of liability is not required. This is based on the Social Security Act, Section 1862(a)(7), Statutory Exclusion. The patient is responsible for 100 percent of the accumulated debt in such instances. The amount that other commercial insurance carriers will pay depends on whether these services are included in the individual’s insurance plan. The Centers for Medicare & Medicaid Services (CMS) does, however, pay for a preventive type of service, initially and ongoing, and that will be addressed later in this article.

In CPT®, codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients 65 and over, for both new and established patients. Preventive medicine services are represented in the E&M codes section of CPT®. These preventive medicine codes may be reported by any physician or other qualified healthcare professional, i.e., a nurse practitioner (NP), advanced practice provider (APP), or physician’s assistant (PA).

Preventive visits, like many procedural services, are bundled services, unlike problem-oriented E&M office visits (99202–99215), which involve medical decision-making based on presenting active and chronic problems, and have complicated coding guidelines. Preventive service documentation is more straightforward. The following components are needed to report a preventive service:

• An age- and gender-appropriate comprehensive history and physical exam;
• A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT®;
• Counseling/anticipatory guidance/risk factor reduction interventions, which are provided at the time of the initial or periodic comprehensive preventive medicine examination;
• Notes concerning age-appropriate counseling, screening labs, and testing; and
• Orders for vaccines appropriate for age and risk factors (and may be reported separately).

According to CPT®, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. Rather, it requires a “comprehensive system review and comprehensive or interval past, family, and social history, as well as a comprehensive assessment/history of pertinent risk factors.” The comprehensive preventive exam differs from a comprehensive problem-oriented exam, because its components are based on age and risk factors, rather than a presenting problem(s).

Coverage of preventive visits varies by insurer, so it is important to be aware of the patient’s health plan. Most plans limit the frequency of the preventive visit to once a year, and not all tests are covered. Fecal occult blood tests, audiometry, pap smear collection, and vaccines and their administration should be billed separately. Visual acuity testing is not separately reimbursed, but many plans will cover behavioral and mental health screenings separately.

Without a new or chronic disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-10-CM code for screening should be assigned on the order form and claim.

When billing for a preventive medicine visit, it may be appropriate to also bill for a problem-oriented E&M visit if “an abnormality is encountered or a preexisting problem is addressed in the process of performing this … service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E&M service; then the appropriate office visit code (99202-99215) should also be reported with a 25 modifier, to reflect a ‘significant separately identifiable service,’” according to the CPT® Professional Edition 2022, page 48.

What you have to be careful of is a patient who presents with well-controlled chronic conditions and no complaints, who is asymptomatic and there to “establish care” with your physician. That may be considered a preventive visit by Medicare and commercial plans.

The following is an example of when to consider billing a separate E&M visit code, in addition to a preventive medicine visit:

Say a family practice physician sees an established patient Medicare patient for their scheduled yearly exam. The patient did not mention any complaints when the appointment was made, and stated that she was scheduling her annual physical only. However, during the course of the visit, the physician found a palpable left breast mass that was of concern, and after completing the preventive exam, also completed a separate work-up for this “undiagnosed new problem.” This finding requires an evaluation and work-up that is separate from a preventive history and physical service. It also required diagnostic testing, and a referral to a general surgeon for consideration.

The services should be coded as 99397 (preventive established patient over 65 years old) and 99214-25 for the evaluation, discussion, and MDM (medical decision-making) of the breast mass presenting problem, along with an assessment and plan (MDM), as this falls into a moderate-level office visit.

If the physician finds a problem while performing an annual physical and the problem is “significant enough” to warrant additional testing, prescribing, or problem work-up, then the appropriate office visit code (99202-99215) should also be reported with a 25 modifier, to reflect the “significant separately identifiable service.” If the patient is presenting as a new patient for a preventive visit and the problem-oriented visit is also needed, this is also reported as a “new patient” visit, according to a CPT® Assistant October 2006, where it states:

“Therefore, if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E&M services as new patient codes (i.e., 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines.” (99201 has been deleted as of 2021.)

Plenty of practice managers have been faced with the question of whether to bill for a preventive medicine visit or an E&M level of service. The answer is relatively simple: bill according to the “intent” of the visit. If the objective is to provide an annual physical to an asymptomatic patient, then a preventive medicine code should be reported. Some sources state that you may bill a preventive medicine visit with a chronic condition such as hypertension or diabetes. If a physician is only managing a patient’s medication and there are no changes or concerns, or another physician is managing the chronic condition and medication for the patient, then it would be appropriate to bill for preventive medicine services. However, if a physician needs to make changes to the medication after finding out that it is causing side effects, utilize a proper E&M visit code, based on the new MDM rules.

This is controversial, but again, the guidelines for preventive services in CPT® reference a subsection that states “if an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine E&M service, and if the problem or 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 99202-99215 should also be reported.”

CPT® goes on to say:

“An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E&M 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.” 

Only the physician can determine if the abnormality is “significant” enough to warrant two E&M services, and many times there is a double co-pay for commercial plans (and a higher out-of-pocket cost for Medicare patients). It may be a better idea to pick either a problem-oriented E&M visit over the preventive medicine visit, and save that for another day. Again, it is a physician’s judgment, based on the level of care that was administered that day. One key to making this decision is that both services cannot be scheduled for the same date. The abnormality to warrant a separate identifiable E&M, above and beyond the preventive visit, has to be found during the wellness check, so it would not be anticipated.

I would not want to see such a decision be based on the patient’s potential out-of-pocket share of cost, but it is a factor, when you consider what the patient scheduled. You’ll find that most patients expect a “free” visit when they schedule a “yearly exam.” It’s important to explain to the patient, prior to charging them for both visits, that two separate services are being performed, so they can expect additional charges. The patient may want to reschedule their preventive visit if there is a dual co-pay involved.

CPT Assistant weighed in on this topic again in 2009, and gave two examples of a preventive visit that was age- and gender-appropriate:

• A preventive Service for a 33-year-old woman may include a pap and pelvic, breast exam, and BP check. Counseling may be for diet, exercise, substance abuse, and sexual activity.
• For a 13-year-old girl, such a service may include a scoliosis screen, and an assessment of growth, development, behavior, and immunizations. Anticipatory guidance may also be offered for health habits, self-care, avoidance of substances, avoiding risks associated with sexual activity, and even wearing a seatbelt while in a car.

Also, know the difference in what you are reporting. For Medicare beneficiaries, there are three options for reimbursable preventative services:

Source: CMS MLN Booklet ICN 006904 August 2018

For additional guidelines regarding preventive medicine and E&M coding, please refer to the American Medical Association (AMA) or CMS website.

Other Reference here.