preventive visit cpt codes

CPT CODE 99381, 99382 – 99385 – Preventive visit new patient

Sep 25, 2016 | Medical billing basics

CPT Code and description

99381 – 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; infant (age younger than 1 year)

99382 – 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; early childhood (age 1 through 4 years)

99383 – 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; late childhood (age 5 through 11 years) – Average fee amount $110 – $130

99384 – 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; adolescent (age 12 through 17 years) Average fee amount $120 – $140

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  –  Average fee amount – $120 – $ 150

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397 , Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse  Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

For a list of specific codes that are included in (and not separately reimbursed from) Preventive Medicine Services see the Applicable Codes section below.

For the purposes of this policy, Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is defined as a physician, hospital, ambulatory surgical center, and/or other health care professional of the same group and Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional reporting the same Federal Tax Identification number.

PREVENTIVE MEDICINE SERVICES, NEW PATIENT

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 appropriate immunizations, laboratory/diagnostic procedures for a new patient.

Code Description

99381 Infant (age under 1 year) 99382 Early childhood (ages 1 through 4 years) 99383 Late childhood (ages 5 through 11 years) 99384 Adolescent (ages 12 through 17 years) 99385 18–39 years 99386 40–64 years 99387 65 years and over

PREVENTIVE MEDICINE SERVICES, ESTABLISHED PATIENT

Periodic comprehensive preventive medicine re-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 appropriate immunizations, laboratory/diagnostic procedures for an established patient.

Code Description 99391 Infant (age under 1 year) 99392 Early childhood (ages 1 through 4 years) 99393 Late childhood (ages 5 through 11 years) 99394 Adolescent (ages 12 through 17 years) 99395 18–39 years 99396 40–64 years 99397 65 years and over

New versus Established client: A new client is defined as one who has not received any professional services from a physician/qualified health care professional in your health department, within the last three years, for a billable visit that includes some level of evaluation and management (E/M) service coded as a preventive service using 99381-99387 or 99391-99397, or as an evaluation & management service using 99201-99205 and 99211-99215. If the client’s only visit to the Health Department is WIC or immunizations without one of the above service codes, it does not affect the designation of the client as a new client; the client can still be NEW. Remember that a client may be new to a program but established to the health department if they have received any  professional services from a physician/qualified health care professional.

In this case, you would use the forms for a “new” patient for that program even though the client is billed as “established” to the health department. Due to National Correct Coding Initiative (NCCI) edits the practice of billing a 99211, and then later billing a new visit code, has been eliminated. Many LHDs have been billing a 99211 (usually an RN only visit) the first time they see a patient and then, up to 3 years later, bills a 99201 – 99205 or 99381-99387 (New Visit). Examples may include: billing the 99211 for pregnancy test counseling or head lice check by RN and then a new visit when the patient comes in for their first prenatal, Family Planning or Child Health visit. Now that the NCCI edits have been implemented, all of those “new” visits will deny because the LHD will have told the system (via billing a 99211) that the patient is “established.” Consult your PHNPDU Nursing Consultant if you have questions.

ADULT PREVENTIVE CARE PROCEDURE CODES

Code Description 76091 Mammogram (specialty center) 82270 Fecal Occult Blood Test (lab procedure code only) 82465 Total Serum Cholesterol (lab procedure code only) 84153 PSA (lab procedure code only) 86580 Tuberculosis (TB) Screening (PPD) 88150 Pap Smear (lab procedure code only) 90658 Flu Shot 90718 Td-Diphtheria–Tetanus Toxoid–0.5 ml 90732 Pneumovax

REIMBURSEMENT GUIDELINES Preventive Medicine Service and Problem Oriented E/M Service

A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.

QUESTIONS AND ANSWERS 1 Q: Why does Oxford reduce reimbursement to 50% for an evaluation and management (E/M) service (99201-99205 or 99212-99215 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine service ?

A: Oxford recognizes that a visit may begin as a Preventive Medicine service, and in the process of the examination it may be determined that a disease related condition exists (evaluation and management). When this occurs, the level of decision-making during such a visit may be more complex than the decision-making during a Preventive Medicine visit. However, there are elements of the Preventive Medicine service (e.g., making the appointment, obtaining vital signs, maintaining and stocking the exam room, etc.) that are duplicated in the reimbursement for an E/M code; these duplicated practice expense services are 50% of the E/M cost.

2 Q: In what situation is CPT code 96110 reimbursable?

A: As defined, CPT code 96110 represents developmental screening with interpretation and report. In the introduction to the section in which this code appears, the CPT book states that “it is expected that the administration of these tests will generate material that will be formulated into a report.” Because a physician obtains developmental information as an intrinsic part of a preventive medicine service for an infant or child and because this information is sometimes obtained in the form of a questionnaire completed by the parents, it is expected that this code will be reported in addition to the preventive medicine visit only if the screening meets the code description. Physicians should report CPT code,  for developmental screening or other similar screening or testing, separate and distinct from the Preventive medicine service only when the testing or screening results in an interpretation and report by the physician being entered into the medical record.

3 Q: Why is Q0091 not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers Q0091 (obtaining, preparing and conveying a cervical or vaginal smear to the laboratory) to be an integral part of a Preventive Health Care service. Therefore, this component of a Preventive visit is not separately reimbursable.

4 Q: Why is 99173 (screening test of visual acuity) not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers vision screening using an eye chart to be integral to a Preventive Medicine examination in the same way that measurements of height, weight and blood pressure are integral to a Preventive Medicine examination. Therefore, vision screening using an eye chart is not reimbursed separately from a Preventive Medicine examination.

5 Q: Why is 99172 (visual function screening) not separately reimbursable when billed with a Preventive Medicine code?

A: The CPT Book clearly states that this service should not be reported in addition to an E/M code.

6 Q: How does Oxford reimburse for screening tests based on a questionnaire completed by the patient or a family member when done in conjunction with a Preventive Medicine service?

A: Counseling, anticipatory guidance and risk factor reduction interventions are integral to a Preventive Medicine visit. Historical information may be obtained either through direct questioning or through completion of a written questionnaire. The responses on a questionnaire often identify areas for more focused interventions or treatments. Since this screening is part of a Preventive Medicine service, it is not reimbursed separately. Occasionally, a screening instrument requires interpretation, scoring, and the development of a report separate from the Preventive Medicine encounter. In those  situations, where a CPT code exists for that service, screening, interpretation and development of a report is reimbursed separately from a Preventive Medicine service. State Exceptions

Arizona Per Arizona State Regulations, effective 4/1/14 claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form for members up to age 21. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier.

EPSDT visits are paid at a global rate for the services specified and no additional reimbursement is allowed. Providers must use an EP modifier to designate all services related to the EPSDT well child check-ups, including  routine vision and hearing screenings.

* A list of preventative, office or other outpatient services that are considered included in the global payment of the preventive medicine CPT code is attached to this policy

*  Ocular photoscreening with interpretation and report, bilateral (CPT code 99174) is allowed for members under age 19. Arizona EPSDT Bundled Codes Lis t

A list of preventative, office or other outpatient services that are considered included in the global payment for the preventive medicine CPT codes (99381 – 99385, 99391 – 99395).

DC EPSDT Well-Child Visit Billing Reference Guide

When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include:

* Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders

* Comprehensive, unclothed physical examination

* Appropriate immunizations (as established by ACIP)

* Laboratory testing (including blood lead screening appropriate for age and risk factors)

* Health education and anticipatory guidance for both the child and the caregiver.i

To bill for a well-child visit:

* Use the age-based CPT code (99381-99385; 99391-99395). See Table 1.

o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code

* Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.

* If a screening or assessment is positive and requires follow-up or a referral, please use modifier TS with the applicable screening code that had a positive result.

DO NOT USE THE E&M OUTPATIENT VISIT CODES (99201-99205; 99213-99215) TO BILL FOR A WELLCHILD VISIT.

Table1: Age Based Preventive Visit CPT Codes Table 2: Screening/Assessment CPT Codes Patient’s Age                CPT Code           Dx Code

< 1 year  99381/91  new/established  V20.31,  20.32,  V20.2

1 – 4 years 99382/92 V20.2

5 – 11 years 99383/93 V20.2

12 – 17 years 99384/94 V20.2

18 – 21 years 99385/95 V70.0

HCY/EPSDT Billing Codes [1][2][3] AGE CPT Code: New Patient AGE CPT Code:

Established Patient Modifiers As Applicable ICD-10-CM Diagnosis Codes Preventive visit, Modifier EP: Used with procedure codes 99381-99385 and 99391-99395 when a Full or Partial screening is performed.

Modifier 52: Used with modifier EP when all components have not been met, but at least the first 5 or more components were completed according to the HCY/EPSDT requirements.

Modifier 59: Used when only components related to developmental and mental health are screened.

Modifier 25: Used on the significant, separately identifiable problem-oriented evaluation and management service when it is provided on (1) the same day as the preventive medicine service and/or (2) with administration of immunizations. Please note that modifier 25 is not to be used on preventive codes and needs to be billed using office or outpatient codes (99201-99215), and that these screenings bundle administration of immunizations.*Documentation must support the use of a modifier 25. See MO HealthNet Provider Manual. Modifier UC: Used when a referral is made for further care.

Z00.110 Newborn under 8 days old

Z00.111 Newborns 8 to 28 days old or

Z00.121 Routine child health exam with abnormal findings

Z00.129 Routine child health exam without abnormal findings Preventive visit, 1-4

99382 Preventive visit, 1-4

99392 Z00.121 Z00.129 Preventive visit, 5-11

99383 Preventive visit, 5-11

99393 Z00.121 Z00.129 Preventive visit, 12-17

99384 Preventive visit, 12-17

99394 Z00.121 Z00.129 Preventive visit, 18 or older

99385 Preventive visit, 18 or older

99395 Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings

NCCI Edit with preventive visits

National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation & Management (E&M) Codes Effective April 1, 2014, the Department will no longer reimburse NCCI procedure-to-procedure (PTP)  edits when immunization administration procedure codes (CPT 90460-90474) are paired with preventative medicine E&M service procedure codes (CPT 99381-99397).

If a significant separately identifiable E&M service (e.g. new or established patient office or other outpatient services [99201-99215], office or other outpatient consultation [99241-99245], emergency department service [99281-99285], preventative medicine service [99381-99429] is performed), the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI  PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an editunder appropriate circumstances. A modifier indicator of “9” indicates that the edit has been deleted, and the modifier indicator is not relevant. The Correct Coding Modifier Indicator can be found in the files containing Medicaid NCCI PTP edits on the CMS website.

A modifier should not be added to a HCPCS/CPT code solely to bypass an NCCI PTP edit, if the clinical circumstances do not justify its use. If the E&M service is significant and separately identifiable and performed on the same day, the E&M code should be billed with the vaccine and toxoid administration codes using PTP associated modifier ‘25’. Modifier ‘25’ is only valid when appended to the E&M codes. Do not append to the immunization administration procedure codes 90460-90474.

Therapeutic Injections Office visits (CPT codes 99201-99205; 99212-99215; 99381-99397) will not be separately reimbursed when submitted with therapeutic injections (CPT code 96372). Please append Modifier 25 to the disallowed E/M code if a significant separately identifiable E/M service was performed. Note: CPT code 96372 has been valued to include the work and practice expenses of CPT code 99211. A modifier will not override this edit.

Visual Acuity Testing CPT code 99173, visual acuity screening test, is separately reimbursable when submitted with preventive office visits (CPT codes 99381-99397). Vital Capacity Vital capacity (CPT code 94150) is considered incidental to the overall service provided, whether an office visit or a procedure, and will not be separately reimbursed.

Payment guidelines

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling,  anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a  preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same  visit. When this occurs, Oxford will reimburse thePreventive Medicine service plus 50% the Problem-Oriented E/M  service code when that code is appended with modifier  25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes. Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes. Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes. Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

Reporting Evaluation and Management Services With Immunizations

E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits ( CPT 99201 –99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.

The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.

• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.

• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not  be reported when the patient encounter is for vaccination only because the Medicare Resource-BasedRelative Value Scale (RBRVS) relative values for the immunization administration codes incl de administrative and clinical services (ie, greeting the patient, routine  vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine questions, preparation and administration of the vaccine, and  documentation and observation of the patient following the administration of the vaccine). However, if the service is medically necessary, significant, and separately  identifiable, it may be reported with modifier 25 appended to the E/M code (99211). Note that the medical record must clearly state the reason for the visit, brief  history, physical examination, assessment and plan, and any other counseling or discussion items. The progress note must be signed with the physician’s  countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during immunization administration, visit  www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers who do not follow the Medicare RBRVS  may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make certain that the guidelines are in  writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.

• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.

• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

• Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.

Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive

medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

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Healthcare Insights

Top 10 preventive medicine CPT codes

Published Feb 20th, 2023

Preventive medicine is a type of medicine that protects patients and communities from avoidable disability, illness, and death. Healthcare providers offer testing, counseling, and immunizations to prevent illness and identify potential health concerns as they emerge.

Preventive medicine is a vital component of healthcare because it promotes overall wellness, reduces the occurrence of illness, and saves resources.

Using data from the Atlas All-Payor Claims Database , we compiled a list of the top 10 preventive medicine CPT codes below.

Fig. 1 Data is from the Definitive Healthcare Atlas All-Payor Claims Database and represents procedure claims for January – December 2022. Data is accurate as of February 2023.

What was the top preventive medicine CPT code in 2022?

The top preventive medicine CPT code was 99396, a preventive visit for an established patient between ages 40 and 64, representing over 20% of all preventive medicine claims and nearly a quarter of total charges in 2022.

The 40-64 age group is particularly susceptible to conditions like breast cancer, colon cancer, and osteoporosis. Preventive services are especially valuable to patients who face greater risk of illness, whether due to age, comorbidities, lifestyle, or other factors.

The table above also indicates that nearly 80% of preventive medicine claims were for established patients versus new patients. This breakdown shows that most preventive medicine services are for patients who have already received care from the provider.

Why do many people forgo preventive care?

Without health insurance , medical care can be costly and difficult to navigate. For this reason, individuals who do not have health insurance often forgo preventive care. A Bankrate survey found that in 2020, 32% of families in the U.S. did not seek medical care in the past 12 months due to cost.

A study from the CDC found four influencers of preventive care . First, and most prominently, was finances, followed by the use of metrics driving change in the healthcare system, and the role of healthcare payors . The final influencing factor was changes in healthcare reimbursement models.

Individuals who do not receive preventive care are at increased risk for disabilities, diseases, and death .

What is a CPT code?

The Current Procedural Terminology (CPT) is a system of codes used for reporting healthcare services and medical procedures. CPT codes increase the efficiency and accuracy of healthcare reporting and billing.

Definitive Healthcare tracks many CPT codes across diagnostic, medical, and surgical areas. This information can give you insight into diagnosis, procedure, and prescribing activity and transform your sales and marketing strategies.

Learn more

To hear more about the long-term implications of pandemic-related delays in care, including preventive care, listen to our podcast with Dr. Mark Pimentel .

Healthcare Insights are developed with  healthcare commercial intelligence  from the Definitive Healthcare platform. Want even more insights? Start a  free trial  now and get access to the latest healthcare commercial intelligence on hospitals, physicians, and other healthcare providers.

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• Top 10 Preventive Medicine CPT Codes

Think of this as your field guide to the rules surrounding Medicare preventive services .

CINDY HUGHES, CPC, CFPC

Fam Pract Manag. 2016;23(4):9-12

Author disclosure: no relevant financial affiliations disclosed.

Editor's note: This article was edited to remove incorrect information about how often intensive behavioral therapy for cardiovascular disease is covered.

Preventive services are a great opportunity to provide high-quality patient care and increase practice revenue. However, like most services provided to Medicare beneficiaries, many preventive services have specific elements that must be captured in the documentation, and not all services are reimbursable when separately reported on the same date.

Previous articles in Family Practice Management have offered tips and tools for providing and documenting the initial preventive physical examination (IPPE, or “Welcome to Medicare” physical) and annual wellness visits (AWVs). (See the FPM topic collection .) This article will focus on Medicare preventive services that may be provided in conjunction with an IPPE or AWV or as stand-alone services by family physicians.

The IPPE, AWVs, and separately reportable preventive services

Any discussion of Medicare preventive services should start with the basic requirements for the IPPE, the initial AWV, and the subsequent AWV. (See “ Elements of the IPPE and AWV .”) A review of what's included in each of these Medicare preventive visits can make it easier to identify services that can be separately reported. Here are two examples:

Advance care planning (CPT codes 99497-99498) is an element of the IPPE and not separately reportable; however, it is separately reportable with an AWV if you add modifier 33 to the advance care planning code. (See more information on modifier 33 in FPM 's “ Coding & Documentation ” department.)

An electrocardiogram (G0403-G0405) may be separately reported in conjunction with the IPPE, but it is not covered as a preventive service with the AWV.

ELEMENTS OF THE IPPE AND AWV

The table “ Preventive services covered by Medicare in 2016 ” shows which services are and are not separately reportable. It is based on published Medicare policy or National Correct Coding Initiative edits; however, practices should verify coverage with their region's Medicare Administrative Contractor (MAC), as interpretations of separately reportable services may vary.

PREVENTIVE SERVICES COVERED BY MEDICARE IN 2016

A downloadable list of Medicare preventive service codes and coverage requirements.

Download in PDF format

Here are a few examples with which you might not be familiar:

High-intensity behavioral counseling to prevent sexually-transmitted infections (G0445) may be paid on the same date of service as an AWV.

Alcohol screening/counseling services (G0442-G0443) may be paid on the same date of service as another visit as long as the visit is not an IPPE.

Prostate cancer screening by digital rectal examination (G0102) is not separately reportable with either an IPPE or AWV.

Documentation tips

The following tips address some commonly overlooked areas when documenting Medicare preventive services.

First, when providing an IPPE or AWV, be sure to document that you have performed all of the required elements of these services. When providing separately reportable services, remember that your documentation of the services must be separately identifiable in the medical record. For example, elements of the AWV cannot also be used to meet the requirements of another separate service. Each person making entries in the medical record should sign and date each entry. If your practice uses separate templates or notes for services provided on the same date, link the documentation so that medical records staff or reviewers are aware of the separate documentation for each service.

When you perform a screening electrocardiogram (ECG) in conjunction with an IPPE, as with a diagnostic ECG, the interpretation and report should be separately identifiable in the medical record and should detail findings, comparative data, and relevant clinical data. This may include axis, rhythm, rate, PR intervals, ST wave changes, and, when applicable, comparison to a prior ECG.

When providing services such as pathology, laboratory, and radiology, note that Medicare requires a physician order. Any services ordered should be specifically documented as part of the preventive service encounter. When a patient is eligible for services because of high risk (e.g., screening for hepatitis-C virus), your documentation should support this (e.g., history of illicit injection drug use). Medicare contractors may request the ordering physician's records to substantiate the services reported by the performing provider.

Finally, for cervical or vaginal cancer screening, pelvic and clinical breast examination (G0101), remember to include at least seven of the following 11 elements:

Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge (1 element),

Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses (1 element),

Pelvic examination (with or without specimen collection for smears and cultures) including external genitalia, urethral meatus, urethra, bladder, vagina, cervix, uterus, adnexa/parametria, or anus and perineum (9 elements).

Also, consider informing eligible patients about Medicare coverage of chronic care management (CCM) services and obtaining and documenting their written agreement to receive these services, which can be initiated after an evaluation and management (E/M) service such as the IPPE or AWV. (For more on CCM services, see FPM 's article series .)

Documenting time

In general, if the service descriptor in CPT includes a time (e.g., alcohol misuse screening and counseling, 15 minutes), Medicare requires that the time must be met or exceeded to report the service. You must document either start and stop times or total time spent providing the individual timed service. However, there are some exceptions. Medicare coverage determinations override the requirement to meet or exceed the time in the code descriptor for the following time-based services:

For G0444, “annual depression screening, 15 minutes,” the Centers for Medicare & Medicaid Services (CMS) will cover annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.

For G0445, “high intensity behavioral counseling to prevent sexually transmitted infection, face-to-face, individual, includes education, skills training, and guidance on how to change sexual behavior, performed semiannually, 30 minutes,” CMS will cover up to two individual 20- to 30-minute sessions annually for Medicare beneficiaries.

Another exception is code 99497, “Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.” In this case, the CPT midpoint rule applies, which states that “a unit of time is attained when the midpoint is passed.” Therefore, advance care planning can be reported after 16 minutes of service. Of course, double check with your payers, as they may have a different policy.

Counseling and intensive behavioral therapy (IBT) services

Coverage requirements for certain counseling and therapy services provided in family medicine settings can be a source of confusion, so here are some important points to keep in mind.

Advance care planning (99497-99498) . This is considered a covered preventive medicine service (i.e., the patient has no out-of-pocket cost) when provided in conjunction with an AWV and reported with preventive service modifier 33. However, with the IPPE, this service is integral and not separately reported. If the patient receiving the IPPE does not want to discuss advance care planning, simply document that end-of-life planning was offered but refused.

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443) . Before you provide behavioral counseling for alcohol misuse, the patient must have received an annual alcohol misuse screening , 15 minutes (G0442) in the same 12-month period. The screening includes obtaining agreement for behavioral counseling. The first session of behavioral counseling may be provided on the same date as the screening, but the time must be met or exceeded and documented for each service. Medicare covers four counseling sessions within a 12-month period.

Annual face-to-face IBT for cardiovascular disease (CVD), individual, 15 minutes (G0446) . IBT for CVD must include encouraging aspirin use for the primary prevention of CVD when the benefits outweigh the risks for men age 45 to 79 years and women age 55 to 79 years; screening for high blood pressure in adults age 18 years and older; and intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular and diet-related chronic disease. 

Face-to-face behavioral counseling for obesity, 15 minutes (G0447), and face-to-face behavioral counseling for obesity, group (2–10), 30 minutes (G0473) . IBT for obesity includes screening for obesity in adults using body mass index measurement, dietary assessment, and intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise. Medicare covers up to 22 visits in a 12-month period for those who see adequate weight loss in the first six months of therapy. You must document a six-month reassessment of obesity and weight loss of at least 3 kg to substantiate additional face-to-face visits once per month for six months.

High-intensity behavioral counseling to prevent sexually transmitted infections (G0445) . This is defined as a program to promote sexual risk reduction or risk avoidance, which includes three broad topics: education, skills training, and guidance on how to change sexual behavior.

Counseling to discuss lung cancer screening by low dose computed tomography (CT) scan (G0296) . Physicians and their staff must do the following:

Determine beneficiary eligibility including age 55 to 77, no signs or symptoms of lung cancer, cigarette smoking of at least 30 pack-years, and, for former smokers, the number of years since quitting,

Determine whether the patient will benefit from the screening by using shared decision making, including a discussion of benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure,

Counsel the patient on the importance of adhering to annual lung cancer low dose CT screening, the impact of comorbidities, and his or her ability or willingness to undergo diagnosis and treatment,

Counsel the patient on the importance of abstaining from cigarette smoking and, if appropriate, provide information about tobacco-cessation interventions,

If appropriate, furnish a written order for lung cancer screening with low dose CT. Written orders for lung cancer low dose CT screenings must be appropriately documented in the medical record and must contain the following information: beneficiary date of birth, actual pack-year smoking history (number), current smoking status, the number of years since quitting smoking (for former smokers), a statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer), and the ordering physician's National Provider Identifier (NPI).

The counseling and shared decision making may be repeated prior to subsequent lung cancer screening by low dose CT but must again include all of the above elements.

Putting preventive services into practice

The eligibility, frequency limitations, documentation, and bundling of preventive services may appear overwhelming. However, the IPPE and AWV are ideal visits at which to inventory which preventive services will benefit the individual patient and to create a plan for providing them. Although the MAC for your region may not allow separate reporting of behavioral counseling services on the same date as the IPPE or AWV, the preventive visit is an ideal time to explain these benefits to your patient and obtain the patient's agreement to schedule future services.

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