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

by  Terry Fletcher, CPC CCC CEMC CCS CCS-P CMC CMSCS CMCS ACS-CA SCP-CA QMGC QMCRC
May 26th, 2022

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.

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This article originally published on May 8, 2022 by ICD10monitor.