Reporting Evaluation & Management (E/M) Services with Wellness or Preventive Medicine Service Encounters

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Oct 17th, 2023

A common conundrum for many organizations is whether the additional information documented in the medical record, outside of the normal requirements for a CPT preventive medicine service, Medicare initial preventive physical exam (IPPE), or annual wellness exam (AWE), is enough to warrant reporting with a significant and separately identifiable Evaluation and Management (E/M) service.

Responding to this concern requires unraveling the requirements of the preventive, IPPE, and AWE services and comparing them to the documentation to determine if there is, indeed, enough information to support reporting the additional E/M encounter.

Understanding the Requirements of Preventive, IPPE, and AWE Services

First, we need to remember that these encounters are meant to provide an opportunity for the provider to do a deep dive into the patient’s medical, social, and family history, perform health screenings, and order and review basic testing to determine the overall health status of the patient. Identifying any specific health risks and educating the patient on how to mitigate these risks is also included in these encounters. While these are actually named preventive or wellness encounters, it does not necessarily mean the patient will be the perfect picture of health. 

According to the National Association of Chronic Disease Directors (NACDD), approximately 60% of Americans currently have at least one chronic condition and 40% have more than one chronic disease. They also attribute two-thirds of all deaths in the United States to be associated with these five chronic conditions: heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes. Preventive health screenings were established for early detection and prevention. With that in mind, consider the purpose of the preventive medicine service as compared to an E/M service encounter. One is for prevention while the other is seeking care for a specific condition, illness, disease, symptom, injury, or other specific need.

Requirements of the IPPE, AWE, and Preventive Service

The following are the three main preventive health service types and code options:

• Medicare
  • Initial Preventive Physical Exam (IPPE) (initial 12 months of Medicare/Part B)
    • G0402
    • G0403-G0405 (EKG testing)
    • G0468 (Performed at a federally qualified health center ([FQHC])
  • Annual Wellness Visit (AWV) (Once every 12 months/Medicare Part B)
    • G0438 (initial)
    • G0439 (subsequent)
    • G0468 (Performed at a FQHC)
  • Other Preventive Medicine Service
    • 99381-99387 (initial comprehensive encounter)
    • 99391-99397 (subsequent encounter)

CPT also provides codes for reporting individual or group preventive medicine counseling services or risk factor reduction interventions. These services are not reportable on the same day as IPPE, AWE, or preventive medicine service examinations. Documentation must include a summary of what was discussed, counseled, or the intervention provided and the total time spent performing it, as these are time-based services. For additional information regarding these services, see FindACode.com, codes 99401-99404 and 99411-99412.

The following include a summary of the Medicare-required components of the IPPE, AWE, and CPT-specific Preventive Medicine Services. Please review each while thinking about the E/M medical decision making (MDM) elements to identify the differences between them.

Initial Preventive Physical Examination (IPPE) Requirements

Covered under the Medicare Part B benefit when performed within the initial 12 months of Medicare enrollment.Deductibles and coinsurance do not apply to this service.  All components must be performed and documented by a physician or qualified nonphysiciain practitioner. 

• Review and document the patient’s medical, social, and family history including
  • Medical/surgical history, medications and supplements, social history, substance use, current opioid prescriptions, diet, physical activity, and pertinent family history
• Physical examination
  • Height, weight, BMI, BP, visual acuity screen, and other factors as appropriate per patient medical/social history and current clinical standards
• Preventive services/screenings
  • Substance use disorder screening, depression risk assessment screening, functional ability assessment screening, hearing impairment screening, activities of daily living, fall risk, and home safety concerns (using standardized screening instruments)
• Preventive services education
  • Any and all patient discussion/education on preventive care, including diet, nutrition, weight, physical activity, dental care, smoking cessation
• End-of-life planning
  • Education, counseling, and referral for services based on the results of the review and evaluation

Annual Wellness Exam (AWE)

Covered under the Medicare Part B benefits once every 12 months with no deductible or coinsurance requirements. All components must be performed and documented by a physician or qualified nonphysician practitioner. Deductibles and coinsurance do not apply to this service. 

• History: Establish or update the prior IPPE medical, social, and family history information and identify all current providers and suppliers involved in the patient’s care
• Physical examination: Height, weight, BMO, blood pressure, other routine measurements as deemed appropriate from review of patient medical/family history
• Preventive Services/Screenings:
  • Health risk assessment per standardized instrument
  • Administer screening/prevention exams, including: Cognitive assessment, depression using standardized instrument, opioid screening, review, and referral as needed; substance use screening (alcohol, tobacco, illicit); functional assessment per standardized instrument; and set up a schedule for the next 5-10 years of screening and prevention services
• Identify and document any risk factors or conditions
  • Establish primary through tertiary intervention requirements (e.g., mental health)
• Patient education
  • Provide any patient education to reduce, prevent, improve risk factors for self management, community-based lifestyle, health risk reduction, promoting self-management and wellness, weight loss, physical activity, smoking cessation, fall prevention, nutrition, etc.
• Establish or Review advance directives
  • May include discussion, explanation, and filling out standard forms, especially if the patient did not have an IPPE

Preventive Medicine Service

Report appropriate CPT code based on initial or subsequent (periodic) preventive exams. 

• Age/Gender-appropriate history and examination
• Provide counseling and anticipatory guidance
• Establish risk factor reduction interventions (e.g., sex, substance use, weight, diet, exercise, dental, body image)
• Age-appropriate lab and diagnostic testing

The preventive services described in detail above are meant to establish a solid understanding of the patient’s health status and current needs or risks associated with chronic illnesses that can impact their health and future. Patients who present for a preventive service are not usually sick patients; however, there are many providers who struggle to convince their patients that when they are well, they should seek to find ways to improve their overall health and well being by ensuring they schedule and attend a preventive medicine service examination.  Therefore, many providers are left to their own devices to convince a patient who presents for a sick visit to return for a wellness check. 

In preparation for the upcoming preventive service, the provider often orders the preventive labs during the sick visit and encourages the patient to have the labs drawn in anticipation for their upcoming preventive service encounter. This brings up another coding issue related to scoring the E/M encounter for a sick visit where the preventive service labs are being ordered in advance. Does the provider get credit under MDM Data ordered/reviewed for ordering the preventive service labs? The answer is no, they do not get to count ordering these labs as part of the MDM scoring for the sick visit because they are an integral part of the preventive service and not at all applicable to the sick visit encounter. 

Reporting Separately Identifiable E/M Encounter with a Preventive Service

Now that we have reviewed what is required by the provider performing the preventive service encounter, whether for Medicare beneficiaries or others, we can review the requirements for reporting a separately identifiable E/M encounter at the same time.

To report an E/M encounter, the documentation must support medical necessity and the MDM or time criteria for each E/M code (99202-99205, 99212-99215). It is important to note that it is highly unlikely a patient will present for a wellness or preventive encounter and have a separately reportable high level E/M service (99204, 99215). If the patient is indeed that ill, it will be difficult to perform a “wellness” encounter, and to avoid accusations of improper billing, it would be better to reschedule the wellness encounter for another date when the patient is in better health. 

A quick review of the CPT coding guidelines under Preventive Medicine Services, reveals: 

The following E/M MDM elements are not included in the list of requirements for reporting wellness or preventive services and as such, can be used to score a separately reportable E/M service: 

• Examination of organ systems affected by an exacerbated chronic condition or acute condition the patient complains about during a preventive or wellness encounter.
• Ordering testing related to an exacerbated chronic condition or acute condition that would not have otherwise been ordered as part of a wellness or preventive medicine service.
• Ordering a new prescription or changing the dosing of a current prescription for treatment of an exacerbated chronic condition or a new acute condition identified during the preventive or wellness encounter.

The CPT guidelines are also clear about the handling of trivial or insignificant problems identified during a preventive or wellness encounter, stating: 

An example of this is when a patient having a preventive medicine service requests a refill of a medication they routinely take for a chronic condition that is stable and requires no additional workup or evaluation. Stable chronic conditions that do not require any additional evaluation or testing do not qualify for reporting as a separately identifiable E/M service. 

When considering whether to report a separately identifiable E/M service at the time of a preventive or wellness encounter, be sure to adhere to all guidelines and review the documentation to ensure it supports the extra work and MDM criteria. When the documentation supports both, append modifier 25 to the E/M service code to override the correct coding edits that would otherwise bundle them and deny the E/M service. Consider separating the two reports within the encounter note to ensure ease in identifying supporting documentation for the E/M service and that all components have been met for the E/M service level reported. Look for documentation patterns that may be questionable or unsupportive and address them to prevent audit inquiries, and always remember the purpose of the preventive/wellness in comparison to the E/M problem-oriented service to ensure all criteria have been met. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.