Preventative Medicine vs. Evaluation and Management Codes

Preventative Medicine vs. Evaluation and Management Codes By Rachel M. Mitchell, CPC-H

Choosing a proper office visit code can become confusing unless one understands the rules separating preventative medicine and evaluation and management coding. Preventative medicine codes are meant only for the reporting of asymptomatic patients. To assign a preventative code, a comprehensive evaluation must be documented.  The scope of a preventative visit depends on the patient’s age and screening test(s) fitting the patient's age. Medicare does not cover the CPT codes 99381-99429 (preventative medicine screening).  A list of Medicare’s covered preventative services can be found here https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html.  No more than one wellness visit per calendar year can be billed.   When billing for a preventative medicine visit, it is legal to also bill for an evaluation and management service if a patient wants a medical problem addressed during their yearly physical exam.  In order to bill an additional qualifying E&M service, you must provide documented proof of medical necessity.   However, note that some insurances will not allow both, so the provider must choose the most prevalent service.  Be aware that many insurances are requiring medical records to be sent for review when both a physical and E&M service are billed on the same day.  Cigna, Anthem, and Aetna are carriers with policies requiring records when -25 modifiers are used. 

Using An Example

The following is an example of when to consider billing a separate evaluation and management code: An internal medicine physician sees an established patient for their scheduled yearly exam (preventative medicine). The patient did not mention any complaints when the appointment was made and stated that he wanted to be seen for an annual physical only. However, during the course of the visit, the physician determines that the patient has an enlarged prostate. This finding requires an evaluation separate from a preventative history and physical. If the internist finds a problem while performing an annual physical, and if the problem is significant enough to warrant additional testing, then the appropriate office visit code 99211-99215 should also be reported. The services should be coded as 99396 (preventative) and 9921X-25 for evaluating and discussing the enlarged prostate. There is a fee stipulation when trying to bill a Medicare patient for preventative medicine and an evaluation and management code. You must subtract the amount of the E&M from the preventative medicine visit and a bill that amount plus coinsurance. Many practice managers have faced whether to bill for a preventative medicine visit or an E&M level of service.  The answer is relatively simple, bill according to the intent of the visit. A preventative medicine code should be reported if the objective is to provide an annual asymptomatic physical. Some sources state that you may bill a preventative medicine visit with a chronic condition such as hypertension or diabetes. If a physician only manages a patient’s medication, it would be appropriate to bill for preventative medicine. However, if a physician needs to change that medication after finding out it is causing side effects, utilize a proper E&M visit code.  Be sure to prepare your patients for billing issues, as billing wellness and a sick visit may affect out-of-pocket financial responsibility.  Patients may not understand the difference between preventative and problem-oriented services or the difference in billing and coding.  Please refer to the AMA or CMS website for additional guidelines regarding preventative medicine and evaluation and management coding.  Ms. Mitchell is the Director of Client Development and Relations for Applied Medical Systems, Inc., a medical coding and accounts receivable management company in Durham, North Carolina. Ms. Mitchell has over 25 years of experience in medical billing, coding, and consulting. For any questions regarding the above editorial, please contact Ms.Mitchell at (919) 477-5152 or [email protected].  the reporting of asymptomatic patients. In order to assign a preventative code, a comprehensive evaluation must be documented. The scope of a preventative visit depends on the patient’s age and screening test(s) fitting the patient's age. Medicare does not cover the CPT codes 99382-99429 (preventative medicine screening). When billing a Medicare patient's preventative medicine visit, a liability waiver is NOT required. This is based on the Social Security Act, Section 1862(a)(7), Statutory Exclusion. The patient is responsible for 100% 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. When billing for a preventative medicine visit, it is legal to also bill for an evaluation and management service if a patient wants a medical problem addressed during their yearly physical exam. The following is an example of when to consider billing a separate evaluation and management code: An internal medicine physician sees an established patient for their scheduled yearly exam (preventative medicine). The patient did not mention any complaints when the appointment was made and stated that he wanted to be seen for an annual physical only. However, during the course of the visit, the physician determines that the patient has an enlarged prostate. This finding requires an evaluation separate from a preventative history and physical. If the internist finds a problem while performing an annual physical, and if the problem is significant enough to warrant additional testing, then the appropriate office visit code 99211-99215 should also be reported. The services should be coded as 99396 (preventative) and 99213-25 for evaluating and discussing the enlarged prostate. There is a fee stipulation when trying to bill a Medicare patient for preventative medicine and an evaluation and management code. You must subtract the amount of the E&M from the Preventative Medicine visit and bill that amount plus coinsurance. Plenty of practice managers have been faced with the question of whether to bill for a preventative medicine visit or an E&M level of service. The answer is relatively simple, bill according to the intent of the visit. A preventative medicine code should be reported if the objective is to provide an annual asymptomatic physical. Some sources state that you may bill a preventative medicine visit with a chronic condition such as hypertension or diabetes. If a physician only manages a patient’s medication, it would be appropriate to bill for preventative medicine. However, if a physician needs to change that medication after finding out it is causing side effects, utilize a proper evaluation and management visit code. Please refer to the AMA or CMS website for additional guidelines regarding preventative medicine and evaluation and management coding. Ms. Mitchell is the Billing and Coding Manager for Applied Medical Systems, Inc., an accounts receivable management company in Durham, North Carolina. Ms. Mitchell has over 10 years of experience in medical billing, coding, and consulting. For any questions regarding the above editorial, please contact Ms.Mitchell at (919) 477-5152 or [email protected]. This article is reprinted with permission from the March 2002 issue of M.D. News magazine.