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Internal Medicine Coding Alert

You Be the Coder:

Reporting E/M With Physical Examinations

Question: Our internal medicine specialist recently saw a patient for his routine physical examination. The patient had a previous history of COPD, GERD, and depression. During the course of the examination, the patient revealed that he has been suffering from a cough for the past two weeks. Our physician checked his symptoms, performed an examination, and prescribed a new medication for the COPD. Can I bill an E/M code for the visit along with the preventive code that I am reporting? 

Vermont Subscriber

Answer: According to CPT®, if an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive medicine evaluation and management (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. That means you may report an office visit in addition to the preventive medicine service if the patient presents with a new or existing problem that requires you to do the additional work of a problem-oriented E/M service, as defined by the history, examination, and medical decision making involved. 
In this situation, your documentation, especially the assessment and the plan, should show that you are actively managing the problem(s) that were described in the history and exam. This could involve new treatment or significant changes to treatment for existing conditions. Do not bill for both services if you are simply reviewing the patient’s existing problems and potentially renewing their prescription.
Since your clinician spent additional time in evaluating the patient’s new symptoms and prescribed new medication to the patient to help overcome the present symptoms, you can report a problem-oriented E/M code (such as 99213, …) in addition to the preventive physical examination E/M code that you are reporting.
Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the problem-oriented E/M code that you are reporting for the evaluation and pharmacological management of the patient to indicate that it did involve significant, additional work beyond that typically included in the preventive E/M service. q