CPT CODE 99381, 99382 – 99385 – Preventive visit new patient

Billing for Preventive Behavioral Services (Postpartum Depression Assessment and other  Mental Health-Related Services)

Multiple sets of billing codes are provided—some for visits completely devoted to preventive services, and some for primary care physician use for mental health diagnosis and patient  management. For most visits, the screening will take less than 3 minutes. Follow-up on screening results can then be billed as diagnosis and patient management.

Benefit packages will differ among and between insurance carriers and different policies offered by a single carrier. Practitioners will have to check with the insurance carrier or managed care plan to decide which codes to use to provide specific services to specific patients.

It is important to note that billing codes are expressed in terms of “encounters,” and that an outpatient visit may include multiple “encounters.” Here again, a provider must inquire with his or her managed care plan or insurance carrier to determine which encounters, within a single

outpatient visit, are to be “bundled,” and which are to be billed separately.

Preventive Medicine, Individual Counseling, and/or Risk Factor Reduction Intervention Provided to an Individual as a Separate Procedure

CPT Code and Approximate Duration of Procedure

99401 – 15 minutes

99402 – 30 minutes

99403 – 45 minutes

99404 – 60 minutes

CPT Code for Initial Evaluation of New Patient (Bold)  

CPT Code for Periodic Reevaluation  Age Range

99381 – 99391 – Under 1 year

99382 – 99392 – 1-4

99383 – 99393 – 5-11

99384 – 99394 – 12-17

99385 – 99395 – 18-39

99386 – 99396 – 40-64

99387 – 99397 – 65 and over

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.

Developmental Screening

Separate reimbursement is allowed for developmental screening (CPT code 96110) when submitted with problem-based (CPT codes 99201-99215) and preventive E/M office visits (CPT codes 99381-99397).

Modifier 25 Modifier 25 may be used to indicate a problem-based E/M office visit (CPT codes 99201- 99215) that is significant and separately identifiable from a preventive office visit (CPT codes 99381-99397) on the same date of service. If Modifier 25 is appended correctly, both services are separately reimbursable.

• Modifier 25 must be appended to the disallowed E/M office visit.

• Please view Clear Claim Connection™ to learn which of the two E/M services is disallowed.

• Documentation is not required to override the edit for problem-based and preventive office visits on the same date of service. 

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).

Procedure CPT Code Modifier

Comprehensive Preventive Medicine (New Patient)

New patient 0 – 11 months 99381 32

New patient 1 – 4 years 99382 32

New patient 5 – 11 years 99383 32

New patient 12 – 17 years 99384 32

New patient 18 – 39 years 99385 32 

Comprehensive Preventive Medicine (Established Patient)

Established patient 0 – 11 months 99391 32

Established patient 1 – 4 years 99392 32

Established patient 5 – 11 years 99393 32

Established patient 12 – 17 years 99394 32

Established patient18 – 39 years 99395 32

BILLING FOR SERVICES TO CHILDREN IN MANAGED CAREORGANIZATIONS (MCOs)

Preventive

New Patient: 1 day – 11 months 99381 Z00.121 Z00.129

New Patient: 1 year – 4 years 99382 Z00.121 Z00.129

New Patient: 5 years – 11 years 99383 Z00.121 Z00.129

New Patient: 12 years – 17 years 99384 Z00.121 Z00.129

New Patient: 18 years – 20 years 99385 Z00.00 Z00.01

Established Patient: 1 day – 11 months 99391 Z00.121 Z00.129

Established Patient: 1 year – 4 years 99392 Z00.121 Z00.129

Established Patient: 5 years – 11years 99393 Z00.121 Z00.129

Established Patient: 12 years – 17 years 99394 Z00.121 Z00.129

Established Patient: 18 years – 20 years 99395 Z00.00 Z00.01

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.

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.

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.