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Preventative Medicine vs. Evaluation and Management Codes
By Rachel M. Mitchell, CPC-H

Choosing a proper office visit code can become confusing unless one understands the rules separating preventative medicine and evaluation and management coding.

Preventative medicine codes are meant only for the reporting of asymptomatic patients. In order to assign a preventative code, a comprehensive evaluation must be documented. The scope of a preventative visit depends both on the patient’s age and screening test(s) fitting the age of the patient.

Medicare does not cover the CPT codes 99382-99429 (preventative medicine screening). When billing a preventative medicine visit for a Medicare patient, a waiver of liability is NOT required. This is based on the Social Security Act, Section 1862(a)(7), Statutory Exclusion. The patient is responsible for 100% of the accumulated debt in such instances. The amount that other commercial insurance carriers will pay depends on whether these services are included in the individual’s insurance plan.

When billing for a preventative medicine visit, it is legal to also bill for an evaluation and management service if a patient wants a medical problem addressed at the time of their yearly physical exam. The following is an example of when to consider billing a separate evaluation and management code:

An internal medicine physician sees an established patient for their scheduled yearly exam (preventative medicine). The patient did not mention any complaints when the appointment was made and stated that he wanted to be seen for an annual physical only. However, during the course of the visit, the physician determines that the patient has an enlarged prostate. This finding requires and evaluation that is separate from a preventative history and physical.

If the internist finds a problem while performing an annual physical, and if the problem is significant enough to warrant additional testing, then the appropriate office visit code 99211-99215 should also be reported. The services should be coded as 99396 (preventative) and 99213-25 for the evaluation and discussion of the enlarged prostate.

When trying to bill a Medicare patient for a preventative medicine and an evaluation and management code there is a fee stipulation. You must subtract the amount of the E&M from the Preventative Medicine visit and bill that amount plus coinsurance.

Plenty of practice managers have been faced with the question of whether to bill for a preventative medicine visit or an E&M level of service. The answer is relatively simple, bill according to the intent of the visit. If the objective is to provide an annual asymptomatic physical, then a preventative medicine code should be reported. Some sources state that you may bill a preventative medicine visit with a chronic condition such as hypertension or diabetes. If a physician is only managing a patient’s medication, then it would be appropriate to bill for preventative medicine. However, if a physician needs to make changes to that medication after finding out that it is causing side effects, utilize a proper evaluation and management visit code.

For additional guidelines regarding preventative medicine and evaluation and management coding, please refer to the AMA or CMS website.

Ms. Mitchell is the Billing and Coding Manager for Applied Medical Systems, Inc., an accounts receivable management company in Durham, North Carolina. Ms. Mitchell has over 10 years experience in medical billing, coding and consulting. For any questions regarding the above editorial you may reach Ms.Mitchell at (919) 477-5152 or at rmitchell@ams-ncl.com.

This article is reprinted with permission from the March 2002 issue of M.D. News magazine.

This article is copyright © 2002 Applied Medical Systems, Inc.