There are a number of preventive codes that should generally be covered.

Family physicians vary in their understanding of preventive care coding.Questions ranged from “What ICD-9 codes are appropriate with preventive care visits?” to “Preventive codes?”What are the preventive codes?I only use E/M codes for evaluation and management.We will define the documentation components necessary to code preventive visits for patients 18 to 64 years old, review the appropriate ICD-9 and CPT codes and how to properly pair them, and discuss the proper use of modifier 25.The Medicare guidelines for preventive visits will not be covered.Below is a list of coding resources for these visits.

Many procedural services are bundled.The documentation of preventive visits is simpler than the problem-oriented E/M office visits.A comprehensive history and physical exam findings are needed, as well as a description of the status of chronic, stable problems that are not significant enough to require additional work.

There is a description of the status of chronic, stable problems that are not significant enough to require additional work.

The comprehensive history that must be obtained as part of a preventive visit has nothing to do with illness.Rather, it requires a comprehensive system review and comprehensive or interval past, family, and social history.

When less than a comprehensive history and exam are performed during a preventive visit, some attempt to use modifier 52 to indicate reduced services.This is not appropriate because it only applies to procedural services.The E/M office visit code may be used to bill preventive visits that do not meet minimum requirements.

Problem-oriented ICD-9 codes are not appropriate to be submitted for a preventive visit.It is possible to link problem-oriented ICD-9 codes with preventive codes.The appropriate ICD-9 codes for preventive care visits can be found in the “Acceptable Codes for Preventive Care Visits” section.

It is important to know the patient’s health plan when it comes to preventive visits.Not all tests are covered by most plans, and the preventive visit is limited to once a year.The administration of vaccines and fecal occult blood tests should be billed separately.It is not reimbursed for visual acuity testing.Without a new or chronic-disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-9 code should be assigned on the order form and claim.

Precautionary clearance is a service that has a preventive purpose.Review of the details is beyond the scope of this discussion, but it is worth mentioning that many private payers cover the preoperative clearance when billed by primary care physicians using E/M codes.

There is a new patient and a established patient.

Administrative physicals include for school admission, camp, and driver’s license.

There is a new patient and a established patient.

Administrative physicals include for school admission, camp, and driver’s license.

Counseling/anticipatory guidance/risk factor reduction interventions are included in the preventive visit codes.When counseling is part of a problem-oriented encounter, it may be billed using preventive medicine codes.If you provide counseling on smoking cessation during a visit for an ankle injury, you could bill if you submit an E/M office visit code for the problem-oriented service.A synopsis of the counseling and ICD-9 codes for preventive counseling should be included in your documentation.The visit requires the use of modifier 25.

You can be paid for both services if you provide a preventive visit with an E/M service on the same day.If the second service requires enough additional work that it could stand on its own as an office visit, use modifier 25.The problem-oriented E/M code should usually have 25 Modifier attached to it.The second service should be attached to the preventive visit code because it is the E/M service.

It’s a good idea to have a separate note for the second service.No one item of documentation can count towards either service.If you don’t have a comprehensive history and exam for the preventive service, a problem-oriented E/M service that requires a considerable amount of work and pertinent documentation may absorb so many of the elements that would otherwise count toward the service.Some doctors give two visits in these situations.

If the separate service can be considered age-appropriate, bundtling is more likely.If a separate E/M note can be written for the problem, then the separate service should not be bundled.See “Appropriate use of modifier 25 during a preventive visit” for examples of complaints that under some circumstances would be handled as part of a preventative visit, but under different circumstances may require additional work that should be billed separately.

Not all carriers pay for services.As part of a class action settlement with multiple state medical societies, Aetna changed its policy and did not reimburse for modifier 25 until 2006The amount of payment for the separate service varies depending on the circumstances in which it is used.Providers have to learn the requirements of each of their payers if they want to use modifier 25 for preventive services.

A 50-year-old with congestive heart failure has been gaining weight.

A 35-year-old with irregular menses.Her entire life has been irregular.There was no change from baseline.

A 50-year-old with congestive heart failure has been gaining weight.

A 35-year-old with irregular menses.Her entire life has been irregular.There was no change from baseline.

Discussing the cost-effectiveness of preventive visits is difficult because of the number of variables to consider.A key variable is time spent per preventive visit.Fee schedule variations, payer mix, productivity variations between physicians, and accuracy of coding are included.

Careful analysis may lead some practices to conclude that preventive care is beneficial to both the patient and the practice.We averaged payment for two visit types from nine actual payers.The visits we considered were a 40-year-old preventive visit and a level-4 established-patient, problem-oriented visit.The preventive visit was 25 percent more expensive than the problem-oriented visit.Unless the preventive visit takes at least 25 percent longer, it will produce more revenue per unit of time.Replacing preventive visits with a larger number of problem-oriented visits could result in more reimbursement, at least in theory.

As recently as 2004, only 1 percent of money spent on health care in the United States was devoted to prevention.TheWelcome to Medicare visit was the first preventive care visit that the Centers for Medicare & Medicaid Services covered.Private payers have been covering preventive visits for a long time.They have long recognized that healthy lifestyle choices and routine health monitoring can reduce the risk of chronic disease.

Regardless of insurance coverage, patients should be offered preventive services even if they have to pay out of pocket.A preventive visit can be done for a patient in the 18 to 64 age range, except for recommended pregnancy-related services.The strongest evidence-based recommendations from the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force are used to create this schematic, which is not intended to reflect all the anticipatory guidance or all of the screening that you might recommend for a given patient.

A board-certified family physician and certified professional coder, Dr. Owolabi is employed by Summit Physician Services, a multispecialty, hospital-owned group practice in Chambersburg, Pa.In addition to managing a busy patient panel, Dr. Owolabi independently offers coding consulting services and speaks and writes on coding topics.Dr. Simpson is a family medicine resident at Phoenix Baptist Hospital.No relevant financial affiliations were disclosed.

1.Center for Medicare & Medicaid Services National Health Expenditures and Selected Economic Indicators, Levels and Average Annual Percent Change can be found in the Office of the Actuary.

2.The future of public health in the 21st century is being explored by the Institute of Medicine.The National Academy Press was in Washington, DC.

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