Coding Corner: CPT reporting for preventive medicine services

September 24, 2018
Area(s) of Interest: Payor Issues and Reimbursement 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

Preventive medicine services, or “well visits,” are evaluation and management (E/M) services provided to a patient without a chief complaint. The reason for the visit is not an illness or injury (or signs or symptoms of an illness or injury), but rather to evaluate the patient’s overall health, and to identify potential health problems before they manifest.

The CPT® codebook includes a dedicated set of codes to describe preventive medicine services, as follows:

  • 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
  • 99382 …early childhood (age 1 through 4 years)
  • 99383 … late childhood (age 5 through 11 years)
  • 99384 …adolescent (age 12 through 17 years)
  • 99385 …18-39 years
  • 99386 … 40-64 years
  • 99387 …65 years and older
  • 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
  • 99392 …early childhood (age 1 through 4 years)
  • 99393 … late childhood (age 5 through 11 years)
  • 99394 …adolescent (age 12 through 17 years)
  • 99395 …18-39 years
  • 99396 … 40-64 years
  • 99397 …65 years and older

Code assignment is determined by the patient’s age (as detailed in the code descriptor), and whether the patient is new (99381-99387) or established (99391-99397). CPT® applies a “three-year rule” to determine “new” vs. “established” status. A patient is established if any physician in a group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months. The “Decision Tree for New Vs Established Patients” in the Evaluation and Management Services Guidelines portion of the CPT® codebook can help you to select the appropriate patient status.

Service Content Varies by Patient Circumstance
Preventive medicine services must include a comprehensive history and examination, and age-appropriate anticipatory guidance. In the context of preventive medicine services 99381-99397, a comprehensive exam is not the comprehensive exam as defined by either the 1995 or 1997 Evaluation and Management Documentation Guidelines. Instead, the exam should reflect an appropriate assessment, given the specific patient’s age and sex. For example, the specifics of the exam will differ for a 4-year-old male and a 22-year-old female.

Services for a young child will assess physical growth (height, weight, head circumference) and developmental milestones such as speech, crawling and sleeping habits. Anticipatory guidance may include use of car seats and other safety issues, introducing new foods, etc.

An adolescent preventive service may include scoliosis screening, assessment of growth and development, and a review of immunizations. Anticipatory guidance may focus on developing positive health habits and self-care, including discussion of drug, alcohol and tobacco use and sexual activity.

A comprehensive preventive visit for an adult female patient will include a gynecologic examination, Pap smear and breast exam. An adult male’s exam would include an examination of the scrotum, testes, penis and the prostate for older patients. Anticipatory guidance may focus on issues of health maintenance, such as alcohol and tobacco use, safe sex practices, nutrition and exercise. The patient’s employment status and other family issues may be discussed. As patient age advances, cholesterol levels, blood sugar and prostate-specific antigen testing may become increasingly relevant.

Diagnoses Must Support Preventive Nature of the Visit
Every billed service must be supported by an ICD-10 code(s) that describe the reason for that service. In the case of a well visit—because there is no patient complaint—you should turn to so-called “Z codes” (Factors influencing health status and contact with health services). For example:

  • Z00.110  Health examination for newborn under 8 days old
  • Z00.111 Health examination for newborn 8 to 28 days old
  • Z00.121 Encounter for routine child health examination with abnormal findings
  • Z00.129 Encounter for routine child health examination without abnormal findings
  • Z00.00 Encounter for general adult medical examination without abnormal findings
  • Z00.01 Encounter for general adult medical examination with abnormal findings
  • Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

You should also code for any abnormalities found, regardless of whether the finding requires an additionally reported service.

Testing and Problem-Focused Testing Are Separate
Per CPT® coding guidelines:

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management 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 99201-99215 should also be reported. Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service.

To determine whether a problem requires “significant” work, consider whether the available documentation is sufficient to support each service (the preventive service and the problem-oriented service), separately.

Additionally, per CPT® coding guidelines, as supported by CPT Assistant (April 2005):

The codes in the preventive medicine services include the ordering of appropriate immunization(s) and laboratory or diagnostic procedures. The performance of immunization and ancillary studies involving laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately.

Payor Coverage May Vary
The Affordable Care Act (ACA) requires insurers to cover recommended preventive services without any patient cost-sharing, but exact coverage and reporting requirements may vary from payor to payor. As CPT Assistant (April 2005) notes:

Codes 99381-99397 are used to report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults. The extent and focus of the services will largely depend on the age of the patient. For example, E/M preventive services for a 28-year-old adult female may include a pelvic examination including obtaining a pap smear, breast examination, and blood pressure check. Counseling is provided regarding diet and exercise, substance use, and sexual activity.

Therefore, based upon this information, it would not be appropriate to separately report for a pelvic exam including obtaining of the pap smear, nor the breast exam as these services are considered part of a comprehensive preventive medicine E/M services.

Although this reporting method reflects the intent of CPT coding guidelines, third-party payers may request that these services be reported differently. Third-party payers should be contacted for their specific reporting guidelines.

Note: Although the CPT Assistant article cited pre-dates the ACA, the advice to contact your payers regarding their reporting requirements remains valid.

Be aware, as well, that Medicare reporting requirements, as stipulated by the Centers for Medicare and Medicaid Services (CMS) often differ from CPT® guidelines. For more information about Medicare Preventive and Screening Services, visit the CMS website.


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