Preventive medicine and office visit, same day

June 1st, 2015 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)   Modifiers   Preventive Medicine Service  
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Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam

Let’s review what a preventive medicine service is, in order to answer that question.  Preventive medicine services are:

• The description given by CPT® for “annual physicals”

• Divided into new and established patient visits

• Categorized by the age of the patient

• Individually listed, with RVUs in chart in appendix

• 99381—99387 for new patient, preventive medicine, delineated by age

• 99391—99397 for established patient, preventive medicine, delineated by age

A preventive medicine service includes:

• Age/gender appropriate comprehensive history and physical exams

• Require anticipatory guidance and risk factor reduction

• Referral for/provision of screening tests and immunizations

• Include treatment of existing problems that “do not require significant extra work”

• Separate payment (per CPT) is allowed for vision, hearing and screening tests, although not all payers pay based on CPT® rules

• Typically, tympanometry is paid separately, but the vision screening (99173) may not be (Although it should be, per CPT

• Many visits have components of both preventive medicine services and “sick” visits

Bill a self pay patient or a commercially insured patient both a preventive medicine and office visit when:  (Medicare and Medicaid have their own rules, of course!)

Can you get paid for both?

• Varies by insurance company

• A separate note helps you to select the level of service for the non-preventive medicine portion of the service

• A separate note shows the insurance company the significant extra work you performed—although it is not required by CPT

CPT® says: “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 be reported.  Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.  The appropriate preventive medicine service is additionally reported.”

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