Important! – The Primary Diagnoses Will Be Different
It is not unusual to perform both a preventive service and a sick visit during the same encounter. CPT and CMS have rules concerning this billing scenario. This month we will cover how to bill for these services using CPT services. Next
month we will cover the Medicare scenarios.
Per CPT Guidelines, if an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management, and if the problem or abnormality is significant enough to require additional work
to perform the key components of a problem-oriented evaluation and management service, then the appropriate office visit should also be reported. In other words, the problem will need to be documented to justify the office visit level of service.
Be sure to include the problem address, data, and risk information. REMINDER: Each of your services will have a different primary diagnosis!
CPT Preventive Medicine Services are billed with codes 99381-99397. These codes will depend on if the patient is new or established and the age of the patient. The preventive visit shall include an age and gender appropriate history, exam, counseling/anticipatory
guidance/risk factor reduction interventions, and the ordering of labs/diagnostic procedures.
If the patient has a problem or an abnormality that is significant enough to warrant additional work the documentation must support the necessary elements to justify the office visit that is billed. Let’s say the patient is 32-year-old female who presents for her annual physical and six-month follow-up for diabetes. The documentation for the office visit must be related to the diabetes.
Example: patient’s home BS are within range, POCT HgA1c 6 indicates well controlled DM2 with diet and medication regimen. Refill Jardiance 25mg.
This A/P justifies the following:
99213 – (2 of the 3 elements must meet or exceed the level of service chosen)
- Problem Addressed: Low – Chronic diabetes, controlled
- Data: Straightforward – Minimal or none (less than 2 tests ordered or reviewed)
- Risk: Moderate – RX Management
IMPORTANT!!!
Be sure to associate the correct diagnoses to each test ordered and each service performed.
Billing:
- 99395 – Preventive Service, est patient 18-39 years (Primary DX – Z00.0 - annual exam)
- 99213 – Office Visit – Low level (Primary DX – E11.9 – diabetes without complications)
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