new patient visit icd 10

New versus Established Patients: Do you Know the Rules and Exceptions?

• By Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM
• February 12, 2019

Not knowing the difference could amount to shortchanging yourself.

It seems like the simpler the question, the harder it can be to answer. When we ask the question, “is this a new or established patient?” it amazes me that it is not a black-and-white answer. But when we look at the American Medical Association (AMA) Current Procedural Terminology (CPT®) definition and the Centers for Medicare & Medicaid Services (CMS) definition, we have to continue to ask. First, let’s examine the textbook definition: Definitions:

New Patient

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management (E&M) services using a specific CPT code(s). A new patient is one who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

Established Patient

An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty, who belongs to the same group practice, within the past three years.

Clear and concise medical record documentation is critical to providing patients with quality care. When billing for a patient’s visit, select the level of E&M service that best represents the service(s) provided during the visit. Services must meet specific medical necessity requirements and the level of E&M performed, based on the CMS 1995 or 1997 Documentation Guidelines for E&M Services.

The rationale for new versus established patients, per CMS, is also based on the provider’s National Provider Identifier (NPI).

Now, when looking at specific examples, it gets a bit trickier when making sure you as a provider are not losing revenue, when there is an opportunity to bill for a new patient visit over an established. However, we also want to be clear when the patient falls into the established patient category and not over-code.

A newborn comes to your practice for her first encounter after leaving the birth hospital, where your group does not have hospital privileges. No physician or qualified healthcare professional had any face-to-face services with this infant in the hospital.

A 7-year old patient returns to your practice. The last face-to-face professional service was a little over three years ago. A little over two and half years ago, you called in a refill for this patient’s allergy medication. (Teaching point: Calling in a prescription does not define a professional service, because there was no face-to-face component.)

You are in a multi-specialty clinic. The patient was seen by a general orthopedic surgeon, but you are board-certified in the hand surgery orthopedic subspecialty and are credentialed with the payors for that. No one in your subspecialty has ever seen this patient, and you are asked to evaluate the patient for wrist pain and possible nerve impingement. (Teaching Point: Because a hand surgeon is considered a “sub-specialty” of orthopedic and has a separate taxonomy code (designation) with Medicare, this qualifies as a new patient visit.)

You are a cardiologist and are asked to read and review an EKG for a patient. You read it (and bill for the reading/interpretation) and call the PCP to have the patient follow up with you for care. The patient presents to your office for the first time (not a consultation). (Teaching point: Reading and billing for an EKG does not count as a professional service, as there is no face-to-face contact with the patient.).

Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code. (Teaching point: since you did not have a face-to-face encounter with the patient when calling in her prescription, this was a new patient.)

A newborn comes to your practice for the first encounter with a pediatrician after discharge from the birth hospital. One of your pediatricians rounded on the baby in the hospital. (Teaching point: Location of service will not matter; a professional service occurred within three years, so they are an established patient.)

You are covering for a general surgeon who is out of town for a few days. You have a coverage arrangement with the surgeon. An established patient of his comes to see you. (Teaching point: When you are “covering” for another physician and his patient sees you, you code based on their establishment with the unavailable physician – if the patient is established to them, the patient is established to you.)

A GI physician leaves one group practice and joins another gastroenterology group. Some of her patients follow her to the new practice. One of the patients who followed was established to the gastroenterologist, presents to the new practice, and sees one of the other GI physicians in the practice. (Teaching point: Because the patient is considered established to the new gastroenterologist, that patient is considered established to all physicians in that new practice who are of the same specialty and subspecialty. A change in address, tax ID, or physical location will not matter.)

The distinction between new and established patients applies only to the categories of E&M services titled “Office or Other Outpatient Services” and “Preventive Medicine Services.” The reason for learning to distinguish new patients from established patients, apart from following coding guidelines, is that it enables you to be reimbursed for the additional work that new patient visits warrant. Another important difference between the codes is that the new patient codes (99201–99205) require that all three key components (history, exam, and medical decision-making) be satisfied, while the established patient codes (99212–99215) require that only two of the three key components be satisfied. So we can argue, in some cases, not distinguishing new patients from established patients can amount to shortchanging yourself. For example, a visit that produces a comprehensive history, comprehensive exam, and decision-making of high complexity qualifies as a level-V visit (99215) if the patient is established and a level-V visit (99205) if the patient is new. The established patient visit amounts to 4.39 NF RVUs ($144.94), while the new patient visit amounts to 6.23 NF RVUs ($205.64). If this was coded incorrectly, the loss to the physician would be $60.70. Think about that as you think about this question once again: is this patient new or established?

Program Note: Listen to Terry Fletcher report this story live today on Talk Ten Tuesday , 10-10:30 a.m. EST.

• TAGS: AMA , CMS , CPT , E&M

Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM

Related stories.

CMS Releases NOFO Application for IBH Model  

An educational webinar on the process is being hosted next month. Federal health officials have announced the release of the Notice of Funding Opportunity (NOFO)

Clinical Documentation Integrity Programs in the Spotlight

All hospitals are struggling to some degree, with increasing payer denials and ongoing post-payment chart reviews resulting in a time-consuming process. According to a recent

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

Mastering E/M Coding: Navigating the Evolving Landscape

Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.

Trending News

The False Claims Act: A Tool Healthcare Industry Plaintiffs Shouldn’t Ignore

UnitedHealth Subsidiary Reports Major Data Breach Affecting Millions of Americans

CMS to Conclude CHOPD Payments: A Response to the Change Healthcare Cyberattack

Unconventional Wisdom Regarding Compliance Issues

Stay connected.

Subscribe to receive free ICD-10 news and updates.

5874 Blackshire Path, #13 Inver Grove Heights, MN 55076

Hours: 9am – 5pm CT Phone: (800) 252-1578 Email: [email protected]

Copyright © 2024 ICD10monitor. Powered by MedLearn Media.

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

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.

Medical Billing Update

• SERVICES PROVIDED BY NON-PHYSICIANS AND RESIDENT PHYSICIANS Payment policy
• What is hospital (UB 04) institutiona claim?
• CPT code G0108 & G0109
• Exceptions to Annual Deductible and Coinsurance
• Medicaid – HMO – 12 Month Enrollment Period

Recent Posts

• Origin and Destination modifiers in Ambulance billing
• CPT code 88120, 81161 – 81408 – molecular cpt codes
• Denial – Covered by capitation , Modifier inconsistent – Action
• CPT code 10040, 10060, 10061 – Incision And Drainage Of Abscess
• CPT Code 0007U, 0008U, 0009U – Drug Test(S), Presumptive
• Medical billing basics

All the contents and articles are based on our search and taken from various resources and our knowledge in Medical billing. All the information are educational purpose only and we are not guarantee of accuracy of information. Before implement anything please do your own research. If you feel some of our contents are misused please mail us at medicalbilling4u at gmail dot com. We will response ASAP.

• ACS Foundation
• Diversity, Equity, and Inclusion
• ACS Archives
• Careers at ACS
• Federal Legislation
• State Legislation
• Regulatory Issues
• Get Involved
• SurgeonsPAC
• About ACS Quality Programs
• Accreditation & Verification Programs
• Data & Registries
• Standards & Staging
• Membership & Community
• Practice Management
• Professional Growth
• News & Publications
• Information for Patients and Family
• Preparing for Your Surgery
• Recovering from Your Surgery
• Jobs for Surgeons
• Become a Member
• Media Center

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

• Membership Benefits
• Find a Surgeon
• Find a Hospital or Facility
• Quality Programs
• Education Programs
• Member Benefits
• E/M Coding and Billing Res...
• Office/Outpatient E/M Visi...

Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

The website will be down for maintenance from 6:00 a.m. to noon CDT on Sunday, June 30.

Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

• Chronic care
• Medicare/Medicaid
• Physician compensation
• Practice management
• Reimbursement
• Value-based payment

Other Blogs

• Quick Tips from FPM journal
• AFP Community Blog
• Fresh Perspectives
• In the Trenches
• Leader Voices
• RSS ( About RSS )

Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use .

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.