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99401 and 99391-95

Cathy Posted Thu 19th of November, 2015 17:29:17 PM

Our physicians sit down with the parents and patient after the well child visit is done and do a consult regarding the visit ie: discuss labs, diet, smoking etc. Can we bill the consult code 99401 with the age appropriate preventative visit E/M code? and would the modifier
-25 go on both codes?

SuperCoder Answered Fri 20th of November, 2015 02:46:22 AM

Thanks for your question.

No, we cannot code this service as a preventive consult because in this visit, physician is consulting regarding the visit. We can increase the level of E/M code as per E/M guidelines for time.

Cathy Posted Fri 20th of November, 2015 13:18:14 PM

So would that mean 99401 can only be used when an exam is not performed or with a non-preventative visit ie:99211-15, would that be correct?

SuperCoder Answered Mon 23rd of November, 2015 05:51:55 AM


Preventive services include exams, shots, lab tests, and screenings. They also include programs for health monitoring, and counseling and education to help you take care of your own health.

Medical treatment for specific health conditions, on-going care, lab or other tests necessary to manage or treat a medical issue or health condition are considered diagnostic care or treatment, not preventive care.

But on the above posted scenario, we cannot decide it for preventive services, for deciding preventive services, need to review report. To code preventive visits below listed components are needed:

A comprehensive history and physical exam findings;
A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT;
Notes concerning the management of minor problems that do not require additional work;
Notes concerning age-appropriate counseling, screening labs, and tests;
Orders for vaccines appropriate for age and risk factors.

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. Rather, it requires a “comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.” The preventive comprehensive exam differs from a problem-oriented comprehensive exam because its components are based on age and risk factors rather than a presenting problem.

Some have attempted to use modifier 52 to denote reduced services when less than a comprehensive history and exam are performed during a preventive visit. This is inappropriate because modifier 52 applies to procedural services only. Preventive visits that do not satisfy the minimum requirements may be billed with the appropriate E/M office visit code.

When submitting a preventive visit CPT code, it is not appropriate to submit problem-oriented ICD-9 codes. Linking problem-oriented ICD-9 codes with preventive CPT codes may delay payment or result in a denied claim. See “Acceptable codes for preventive care visits” for the appropriate ICD-9 codes and the HCPCS and CPT codes with which to pair them.

Coverage of preventive visits varies by insurer, so it is important to be aware of the patient’s health plan. Most plans limit the frequency of the preventive visit to once a year, and not all tests are covered. Fecal occult blood tests, audiometry, Pap smear collection, and vaccines and their administration should be billed separately. Visual acuity testing is not separately reimbursed. Without a new or chronic-disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-9 code for screening should be assigned on the order form and claim.

Another service that has a preventive purpose is the preoperative clearance. Review of the details of this encounter is beyond the scope of this discussion, but it is worth mentioning that many private payers cover the preoperative clearance when billed by primary care physicians using consultation E/M codes (99241-99255).

Cathy Posted Mon 23rd of November, 2015 13:13:56 PM

Does another E/M code need to be on the claim with 99401 or can it be billed alone? and if another E/M code is billed, does a modifier need to be put on the 99401?

SuperCoder Answered Tue 24th of November, 2015 06:53:14 AM


Preventive services can be billed alone.

if another E/M code is billed with preventive visit codes, then we can append the 25 modifier to the E/M code to indicate that a significant, separately identifiable service was provided by the same physician on the same date as the preventive service. Also, bill the preventive medicine code with the GY modifier, indicating that the service is statutorily excluded, does not meet any Medicare benefit, or, for non-Medicare insurers, is not a contract benefit.

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