How to Code for ‘Problem’ Discovered During Preventive Medicine Visit

The Current Procedural Terminology (CPT) manual offers guidelines on how to code for a “problem” that is addressed during a preventive medicine service. The guidelines cover “insignificant or trivial” problems as well as those that are “significant.”

“An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported,” according to the manual.

“If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine E/M 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 E/M service was provided on the same day as the preventive medicine service.”

While CPT does not define what qualifies as “insignificant or trivial” vs. “significant,” consider the following key issues before reporting a separate E/M service in addition to the preventive medicine service:

1. Significant – Would the presenting problem have required a separate encounter?

2. Separately identifiable – Did the E/M service require the key components: history, exam and medical decision-making (MDM), or considerable counseling or coordinating care time?

3. Documentation – Is there additional documentation for the E/M service?

While not absolutes, some issues that can support separate E/M reporting include:

new condition that requires additional work (e.g., strep throat, depression);
exacerbation of a chronic condition (e.g., worsening acne);
new or changed prescription; and
required follow-up for certain conditions (e.g., asthma, attention-deficit/hyperactivity disorder).

The following are likely to be identified as incidental:

refill of a medication with no exacerbation (e.g., nasal spray, acne medication);
minor complaint or finding with very minimal work (e.g., mild diaper rash, mild upper respiratory infection) that may not have resulted in the patient coming in for a separate appointment; and
chronic condition that is stable and not required to be addressed (e.g., atopic dermatitis).

Coding tips

Unless billing based on time, history and MDM are the elements typically used to determine the E/M level because more often the exam falls under the “age appropriate exam” subsumed by the accompanying preventive medicine service.
For new patient encounters, you may bill both codes as “new” patient status; however, you will need to meet the level for all three key components (history, exam and MDM) for the E/M unless billing based on time.
Separate documentation makes correct E/M code level identification easier for the physician and the auditor.
You may bill based on time only if the time spent in counseling and/or coordination of care is more than half the total time spent during the encounter. If billing based on time, only count the time spent addressing the “problem”; do not count any time spent on the preventive medicine service.
The preventive medicine service itself is comprehensive since it includes screening for and anticipatory guidance on age-specific developmental and behavioral risk factors. In pediatrics, physicians follow Recommendations for Preventive Pediatric Health Care/Bright Futures in providing preventive medicine services.
A separate E/M office visit code is required when management of chronic conditions is needed or new problems are evaluated/treated.

One challenge to reporting preventive medicine services with an office visit to address an acute or chronic problem is that parents may not be prepared for the cost-sharing, for which they most likely will be responsible. It is important to establish an office policy so families are aware of their financial responsibilities (see resources).

Coding examples

A physician spends 45 minutes during a well-adolescent exam for an established patient. The preventive service takes 25 minutes, while 20 minutes is spent addressing the patient’s history of depression and thoughts of suicide. Of those 20 minutes, all are documented as counseling time.

99394 [Preventive medicine service, 12 through 17 years] Link to Z00.121 (encounter for routine child health examination with abnormal findings)

99213 25 [20 minutes of time of which more than half was spent in counseling] Link to F33.8 (other recurrent depressive disorders) and Z91.5 (personal history of self-harm)

A physician sees a 6-year-old for a preventive medicine service. During the exam, it is noted that the patient has a red throat. After taking a history of the present illness and looking at the patient’s history, a strep test is run and it is positive. The patient is prescribed antibiotics. An expanded problem-focused history and low MDM is documented in addition to the preventive medicine service.

99393[Preventive medicine service, 5 through 11 years] Link to Z00.121

99213 25 [History: Expanded Problem Focused; MDM: Low] Link to J02.0 (streptococcal pharyngitis)

Additionally, report the CPT code(s) for the appropriate strep test(s).


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