Problem-focused and Well Visit

Question: If a patient comes in for a routine physical but he also has a new problem or he wants to discuss a past medical problem, can we bill both 99386 and a 99213 or 99214 with modifier -25?

Answer: CPT instructions indicate that if an abnormality is encountered at the time of a preventive visit, it is appropriate to report an outpatient E&M code (99201-99215) with a -25 modifier in addition to the preventive medicine service. The documentation in the medical record should support the performance of a significant, separately identifiable E&M service in addition to the preventive medicine service.

The diagnosis for the preventive care service is linked to the preventive visit and the diagnosis for the problem is linked to the problem visit on the claim form.

The issue becomes one of the payer’s payment policies. Many payers do not cover a preventive and a problem visit on the same date regardless of the CPT instructions.

I suggest that you appeal the denials with documentation, confirm the payer’s policy regarding this issue, and provide the families with the CPT information and the payer’s response if you have trouble getting paid.