Let’s say a patient comes in for a preventive medicine service and you end up also treating an acute or chronic problem. How do you quickly determine if you should add a second service and bill for a separate problem-oriented visit? In other words, when should you bill an office/outpatient service (CPT codes 99212-99215) on the same day as a preventive medicine service (CPT codes 99381-99397) or a Medicare wellness visit (HCPCS codes G0402, G0438, or G0439)?
Here’s some quick guidance from CPT: If a new or existing problem is addressed at the time of a preventive service and is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service, you should bill for both services with modifier 25 attached to the latter. Likewise, the Center for Medicare & Medicaid Service’s (CMS) guide to wellness visits states that when you furnish a significant, separately identifiable, medically necessary E/M service with a wellness visit, add the E/M service with modifier 25. “That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member,” says CMS.
In your documentation, you should describe in the history of the present illness all of the patient’s acute or chronic conditions and should detail in the assessment and plan how you managed them, making sure to show your extra cognitive work. This could include ordering or reviewing diagnostic tests, renewing prescriptions, making referrals, or implementing other changes to treatment. Note that neither CPT nor CMS requires a change in treatment to support billing for a second separate service.
Family physicians are sometimes reluctant to add this second service because they know the patient will be charged a copay or, depending on the deductible, the full fee for the problem-oriented visit. However, performing two services but charging for only one isn’t reasonable for practice revenue and doesn’t follow CPT rules.
— Betsy Nicoletti, a Massachusetts-based coding and billing consultant
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights," featuring practical, peer-reviewed advice for improving practice, enhancing the patient experience, and developing a rewarding career.