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E/M: Recoup Pay for Same Day Preventive and E/M Services—If You Follow This Advice


- Published on Mon, May 14, 2018

Find out which modifier you need to have on hand.

Your ob-gyn's documentation warrants an E/M code at the same time you're reporting a preventive medicine code-but is that even possible? The answer is yes, but you need to meet certain conditions.

Analogy: If you're bringing your car in for an annual winterization and the mechanic says you need a new carburetor, then you will have to pay for both services, says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wis. The mechanic will charge for both the winterization and the new carburetor. Therefore, you should bill both a preventive and problem E/M visit.

First, Perfect How You Code Preventive Services

When a patient comes in for her annual visit, some commercial carriers want you to apply a preventive medicine service code. This code includes obtaining the Pap sample and preparing the slide as part of a comprehensive preventive medicine service.

The correct preventive medicine code depends on the patient's:

  • status - new or established
  • age.

For instance, if your ob-gyn sees a new patient, you'll likely report one of three codes:

  • 99385 (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; 18-39 years)
  • 99386 ( ... 40-64 years)
  • 99387 ( ... 65 years and older).

Example: Your ob-gyn sees a new 55-years-old patient for a physical for her annual Pap smear and to obtain an order for a screening mammography. The ob-gyn performs a physical based her age and risk factors. You should report 99386.

If the patient is established, you should report one of these codes:

  • 99395 (Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender- appropriate history... established patient; 18-39 years)
  • 99396 (... 40-64 years)
  • 99397 (... 65 years and older).

Example: A 34-year-old established patient comes in for her physical exam, and the ob-gyn orders a urine analysis (UA). The UA comes back with blood. You still report 99395, as your ob-gyn ordered the UA for screening purposes.

Avoid These Preventive Pitfalls

There are a few areas where coders often make mistakes regarding preventive visit claims. For instance, you should take into that account Medicare never accepts preventive codes.

Keep in mind: "The preventive medicine service for an overweight smoker with a family history of breast cancer is going to be different from a non-smoking fitness instructor with no family history," Rasmussen points out. Also, the insurance carrier will determine whether it will cover the service because reimbursement depends on the patient's policy.

Warning: Do not use alternative problem E/M codes to attempt to obtain payment. For instance, don't code a well exam with 99201-99215 for a patient's preventive medicine service to get the service covered. Coding in this fashion can be construed as coding for reimbursement instead of based on correct coding guidelines. You should instead select the E/M code based on the visit's purpose (preventive medicine service or sick visit).

Confront the E/M Plus Preventive Service Scenario

Now that you know how to code preventive visits, check out how to report both a preventive visit and an E/M visit at the same encounter.

Scenario 1: A 21-year-old established patient comes in the office. Notes state: "Here for annual Pap. No acute problems. She would like to learn how to do self-breast exams. In the physical exam: Doctor reviewed the patient's history and did a complete review of systems, then did a general, chest, abdominal, GU-female examination, and took a Pap smear specimen." You should report 99395 with diagnosis code Z01.41- (Encounter for routine gynecological examination...) with the last character specifying either 1 (...with abnormal findings) or 9 (...without abnormal findings).

Heads up: If you are billing a preventive visit, then your diagnosis and CPT® code should coincide.

Scenario 2: Suppose the same patient came in for her annual and complained of irregular intermenstrual bleeding for 3 months. Then you would bill the preventive service (99395) linked to code Z01.41-, as well as an established patient office visit code (9921X) with 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) if the provider documented this problem using the required key elements for a problem E/M service. You would link N92.1 (Excessive and frequent menstruation with irregular cycle) to the E/M code.



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