Coding E&M for Preventive Services

November 17, 2016

This month's coding column looks at whether or not you can count addressing routine chronic conditions without a change in plan of care as E&M.

Q: I have a question about E&M coding along with annual physicals/wellness. If you address routine chronic conditions without a change in plan of care (just going over pertinent labs and refilling meds), can that count as E&M, assuming you've included relevant history of present illness (HPI), physical, and assessment/plan (A/P)?

If a chronic problem is stable and exhibits no symptoms, would a patient's chronic condition be viewed as a trivial or insignificant problem?

Do you then need to downcode the E&M since components of the E&M are already included in the physical? 

A: We get this question a lot and it's important to dispel this rumor once and for all. The answer to this question is that if you assess a problem and address it, particularly in the HPI and A/P - it is a billable service whether it is done with a preventive service or not. 

The subsection guidance for preventive services in the CPT manual (and this has been unchanged in that specific language since the mid 90s) covers this. It clearly says 'if a pre-existing problem is addressed...and if it is significant enough to require additional work to perform the key components of a problem-oriented [E&M].... then the appropriate code ..... should be billed.'

The whole paragraph (also a bit paraphrased) says 'an insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E&M and does not require additional work and the performance of the key components of a problem oriented E&M service should not be billed. 

The key words here are ' performance of the key components of a problem oriented E&M service,' not whether a problem can ultimately be described as especially consequential. 

The words 'trivial and insignificant' are a bit deceptive. They 'characterize' a problem as minor, diminishing it. In part the words address the nature and severity/degree of a problem - but do not really address whether a problem is acute or chronic, or a chronic problem with an exacerbation. A chronic problem requires assessment and management periodically precisely so that it does not progress, become exacerbated or worsen in some way. So the fact that a problem is 'chronic' does not 'trivialize' it.

CMS says the same thing with reference to modifier 25:

When the physician or qualified [non physician provider], or for [annual wellness visit] (AWV) the health professional, provides a significant, separately identifiable medically necessary [E&M] service in addition to the [initial preventive physical examination] (IPPE) or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances.

NOTE: Some of the components of a medically necessary [E&M] service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of [E&M] service to be billed for the medically necessary, separately identifiable, [E&M] service.

Both the AMA and CMS make clear provision for E&Ms for problem management to be billed along with prevention as above. It becomes solely an issue of whether the physician documents enough to support the work.

This really is about how well it is documented. What you may be seeing is providers simply 'naming' or listing problems in the HPI, with no 'status' or detail - and then giving them the same short treatment in the A/P - 'continue same', 'refill all' etc.

These types of notes certainly give the sense or impression of 'trivial' or 'insignificant' - or at least the documentation has that skimpy feel and look to it. This type of treatment in the note gives some basis to the idea that mere 'mentions' of problems do not support any additional management that may have occurred.

The truth of this situation is 'in the telling'. How well does the physician document the

'significant, separately identifiable' service that was provided? If you call it 'refills', and find ways to simply mention things as if in passing, then that's what trivializes it. But you have the liability for every prescription you write, own the work and take the credit as well.

If providers did this well every time you probably wouldn't have to ask this.