Billing Preventive Medicine Visits With a Problem-Oriented E/M: What Providers Need to Know

It is common for patients to schedule an annual preventive exam while also presenting with an active medical issue that requires attention. Proper coding for both services ensures accurate reimbursement and adherence to compliance standards.

Preventive Visits: Commercial vs. Medicare

For commercial insurance plans, preventive visits are billed using CPT codes 99381–99397. These codes cover routine screenings, age-appropriate counseling, and a general physical assessment. Medicare uses separate HCPCS codes for wellness services:

• G0402 – Initial Preventive Physical Exam (“Welcome to Medicare”)
• G0438 – Initial Annual Wellness Visit
• G0439 – Subsequent Annual Wellness Visit

Medicare wellness visits do not include evaluation or management of existing or new medical conditions.

When Both Services Are Billable

When a patient presents with a distinct, medically necessary problem during a preventive or wellness visit, such as new symptoms, chronic disease management, or medication adjustments, a separate problem-focused E/M service (99202–99215) may be billed in addition to the preventive or wellness service.

Documentation Guidelines

To justify billing both services, the medical record should clearly demonstrate:

1. Separate evaluation and management beyond what is included in the preventive/wellness visit.
2. A dedicated assessment and plan for the medical problem(s).
3. Medical decision making or time specifically spent on the problem-focused E/M.
4. Distinct organization in the note, using headers such as “Preventive Exam” and “Problem Visit.”

Without clear separation, payers may deny the additional E/M as overlapping with the preventive service.

Modifier Requirements

Apply modifier 25 to the problem-focused E/M code when billing alongside a preventive or Medicare wellness visit:

• 992xx-25 + Preventive CPT (9939x) or Medicare wellness code (G0438/G0439/G0402)

Modifier 25 signals that the E/M service was significant and separately identifiable from the preventive service.

Examples of Billable Problem-Focused Services

• Adjusting medications for chronic conditions like diabetes or hypertension
• Evaluating new complaints or acute symptoms
• Reviewing and addressing abnormal lab or imaging results
• Counseling or coordinating care for a specific condition

Minor complaints or routine follow-up of stable conditions usually do not qualify for a separate E/M.

Best Practices for Providers

• Structure documentation to clearly separate preventive and problem-focused components.
• Ensure medical necessity for the additional E/M is obvious.
• Educate clinicians on correct use of modifier 25.
• Confirm payer-specific rules, particularly for Medicare Advantage plans.

• The current CMS list of covered preventive services can be found in the Preventive Services Quick Reference Chart.

Struggling with preventive vs. problem-focused E/M billing? AMS can review your documentation, audit your coding, and train your staff to ensure accurate coding and optimal reimbursement. Connect with an AMS Coding Expert→ Written By: Rachel Mitchell CPCI, COC is the Director of Client Development and Relations for Applied Medical Systems(AMS). With over 30 years of hands-on experience in medical billing, coding, and consulting, she helps practices optimize their financial health and operational efficiency. A certified coder and coding instructor, Rachel brings deep expertise to the real challenges of running a medical practice, from ensuring accuracy and compliance in coding to developing comprehensive HIPAA policies and restructuring business operations for optimized workflow. She writes about the strategies that deliver smoother operations and sustainable growth.