Coding Preventive Care Services
by Dianne Wilkinson, RHIT
According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they need it.”1 The organization cites the potential to save more than 100,000 lives annually by simply increasing the use of just five preventive services, including providing smoker counseling and assistance to quit and breast screening for women.
Submitting claims for preventive medicine services can be a challenge, and not all third-party payers reimburse them. This article reviews Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services provided in the physician office setting.
Coding Guidelines for CPT Preventive Medicine Services
In CPT, preventive medicine services are represented in evaluation and management (E/M) codes 99381–99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.
CPT codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.
Documentation requirements for a preventive visit such as an “annual physical” include an age- and gender-appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions. CPT codes for immunizations and ancillary studies such as laboratory and radiology are reported separately. The preventive medicine comprehensive examination documentation requirements represent significant work for the physician or other provider, and payer fee schedules appropriately reflect that work.
CPT codes 99401–99409 report counseling risk factor reduction and behavioral change intervention services provided at an encounter separate from the preventive medicine examination. Individual preventive medicine counseling codes 99401–99404 are used to report counseling services in areas such as family problems, diet, and exercise.
New 2008 CPT codes 99406–99409 for individual behavioral change are available to report intervention services for patients with a behavior typically regarded as an illness, such as smoking or obesity. Group counseling and other preventive medicine services are reported with codes 99411–99429.
Physician practice office staff can encounter administrative challenges for accurate claims submission for preventive medicine services. Unfortunately not all third-party payers reimburse for these services. Among those who do, coverage guidelines and policies can vary greatly from payer to payer.
If the physician practice has a large Medicare patient population, it is a challenge for all clinicians to stay current with the Medicare preventive medicine coverage policies. This is crucial, because physicians are most often the ones discussing coverage issues and presenting patients with advance beneficiary notices (ABNs) required by Medicare when the patient is likely to be held financially responsible for a service that may be denied due to coverage policy.2
For example, Medicare covers many preventive services and screenings such as cancer screenings, immunizations, and cardiovascular disease screening. The Medicare preventive services coverage policies include specific HCPCS/CPT and ICD-9-CM codes for reporting types of beneficiaries who are covered, various screening coverage frequency, and beneficiary payment responsibility.
Also, with the exception of the one-time Medicare initial preventive physical exam, Medicare does not cover annual or “routine” physicals.3 Therefore, Medicare does not provide reimbursement for the CPT comprehensive preventive medicine services codes.
Tips for Coding Combined Preventive E/M and Problem-Oriented Service Visit
It seems logical for physicians to treat a patient’s chronic or new illness during a preventive medicine office visit. However, this may present challenges related to coding and reimbursement under some third-party preventive medicine payer policies.
Physician practices that approach patient visit opportunities to deliver same-day preventive medicine care and problem-oriented chronic or new illness care should consider the following suggestions:
Medicare Same-Day Preventive Service and E/M Visit
An established 67-year-old female Medicare patient presents for a comprehensive annual exam including screening pelvic exam, breast exam, and screening Pap test. (For the purpose of this example, this patient is considered low risk under the Medicare preventive service coverage policy, and the screening pelvic and breast exams and collection of the Pap test are covered for this visit.5) During the visit a level III problem-oriented service is also performed for follow-up of hypertension and type II diabetes.
In this particular patient encounter there are services that are always covered by Medicare (level III E/M problem-oriented service), services that are not covered (comprehensive annual exam), and services that are covered under certain coverage conditions (screening pelvic and breast exams and screening Pap test).
When providing a noncovered preventive service to a Medicare patient on the same date as a covered preventive screening service and a covered E/M problem-oriented service, Medicare requires the physician to “carve out” the cost of any covered service from the charge for the preventive service.
As shown in the table above, modifier GY is appended to code 99397 to indicate a statutorily Medicare noncovered service. Modifier GA is appended to codes G0101 and Q0091 to indicate a valid ABN is obtained and on file. Modifier 25 is appended to code 99213 to identify a significant and separately E/M service was performed by the same physician on the same date of service as preventive screening services. All covered service fees (G0101, Q0091, and 99213) are deducted from the preventive medicine service.
Ensuring Coding and Claims Accuracy
Following are some additional important coding and claim processing points to ensure accurate preventive medicine service reimbursement:
As in the physician-patient relationship, HIM coding professionals are important advocates in the US preventive medicine initiative through sharing their coding, reimbursement, and compliance knowledge with clinicians, patients, and third-party payers. HIM coding professionals are in a position to promote the need for clinicians to participate in available physician quality improvement reporting initiatives that will contribute to vital quality national preventive care healthcare statistics.
AHIMA. “Standards of Ethical Coding.” Available online at www.ahima.org/infocenter/guidelines/standards.asp.
AMA. CPT Assistant, August 2005.
AMA. CPT Assistant, April 2007.
CMS. “The Guide to Medicare Preventive Services.” Available online at www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.
CMS. In “Preventive and Screening Services.” Medicare Claims Processing Manual. Available online at www.cms.hhs.gov/manuals/downloads/clm104c18.pdf.
Dianne Wilkinson (firstname.lastname@example.org) is director of quality management at Med South Healthcare in Dyersburg, TN.