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Coding for Both a Preventive Service and Problem-oriented Visit


Sometimes patients show up for preventive care and an urgent problem. Should you eat the cost for one service? Or bill for both?

doctor with patient

What doctor hasn't heard this before: "While I'm here, I'd like to discuss a few problems."

The patient presents for an annual preventive medicine service and arrives in the exam room with a long list of concerns, questions, and complaints; some pre-existing and some new. The clinician wants to discuss screening tests, healthy behaviors, and risk factor reductions, but the patient has another agenda. So what do you do?

There are three possible solutions, none of them perfect for this situation: provide two services for the price of one; ask the patient to schedule another appointment; or bill for both. Each of these is coded differently and each has financial and patient satisfaction implications.

The CPT book states:

"If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/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."

The May 2002 CPT Assistant newsletter provides additional detail and clinical vignettes on this topic. Its examples include treating both new and established problems, and recommend reporting both the preventive medicine service (99381-99397) and a problem-oriented visit. The problem-oriented visit is reported with the diagnosis for the condition that is treated, and the preventive medicine service is reported with a diagnosis code for an examination. Append modifier -25 to the problem-oriented visit.

A preventive medicine service is an age and gender appropriate history and exam and includes anticipatory guidance, a discussion about risk factor reduction, and provision or referral for immunizations and screening tests. The history recorded, the exam performed, and the content of advice will vary by the age and gender of the patient.

A problem-oriented visit is one that addresses an acute or chronic condition and documents history, exam, and medical decision making related to the condition.

1. Two for the price of one

Some clinicians report only a preventive medicine service, even when addressing multiple acute or chronic issues. Why? Medical practices report that many payers won't reimburse for the second service and that patients, expecting a free preventive service, are angry when there is a copay or the charge goes to the deductible. It is true: Collecting from insurance companies is difficult, most state Medicaid programs will only pay for one E&M on a calendar date, and patients are angry when they get a bill for a service they thought was free, yet has a cost. But, is this reason enough to provide two services for the price of one? "I'll have the hamburger and the fish and chips, but only charge me for the hamburger."

2. Set up another appointment

For a patient in a medical crisis, the clinician will reschedule the preventive service. But, this is also an option for a patient with multiple problems to address. Tell the patient there isn't time to do his annual exam and address his list of seven problems. Perform one that day and re-schedule the others. If the clinician does the physical, ask the patient to identify his most pressing concern and treat it.

3. Perform and bill for both

If both services are done, follow the CPT rules and report both the preventive service and the problem-oriented visit. The patient will be charged a copay for the problem-oriented visit, or may be charged full fee for that visit, depending on her insurance coverage. Be prepared for complaints, and be sure the documentation is complete.

Some coders recommend two notes, one for the preventive service and one for the problem-oriented visit. This isn't very practical in EHR. But, if reporting both, take care in documenting the part of the visit that supports the non-preventive portion of the visit. In the history of the present illness, describe the patient's symptoms or her chronic conditions. Don't conserve words. "HTN-stable; DM-okay; Lipids-will check," will hardly justify the addition of a problem-oriented visit.

Also, if the entire HPI is copied from a previous visit, don't report an additional visit. In the HPI, document pertinent positive and negative systems related to the presenting problem. In the assessment and plan, list the conditions treated and changes to the treatment. You should be more likely to report a problem-oriented visit when there is a new acute condition, a worsening chronic condition, a diagnostic test was ordered, or a treatment was changed. Refilling prescriptions for existing problems is not sufficient work to report a problem-oriented visit, in addition to the preventive service.

Clinicians in the same practice group may have different philosophies and practices regarding this issue. It is useful to discuss these with the billing and coding staff and to develop a written policy. Consistency in implementing the policy helps both clinicians and staff answer patient questions.

Betsy Nicoletti is the founder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com or 802 885 5641.

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