CPT CODE 99391, 99395, 99396, 99397, 99394 – Preventive Exam

CPT CODE AND Description

99391 – Periodic comprehensive preventive medicine reevaluation 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, established patient; infant (age younger than 1 year) – Average fee amount $90

99392 – Periodic comprehensive preventive medicine reevaluation 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, established patient; early childhood (age 1 through 4 years)  Average fee amount $105


99393 – Periodic comprehensive preventive medicine reevaluation 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, established patient; late childhood (age 5 through 11 years) Average fee amount $110

99394 – Periodic comprehensive preventive medicine reevaluation 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, established patient; adolescent (age 12 through 17 years) Average fee amount $120

99395 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 18-39 years


99396 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 40-64 years


99397 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 65 years and older

Referral/notification/preauthorization requirements

There are no referral/preauthorization requirements for well baby/well child care visits when provided by a contracted FCHP primary care physician within the member’s product network.

Billing/coding guidelines

For new patients making a well baby/well child care visit:

• For infants under age 1, use CPT code 99381.

• For children ages 1 to 4 (early childhood), use CPT code 99382.

• For children ages 5 to 11 (late childhood), use CPT code 99383.

• For children ages 12 to 17 (adolescent), use CPT code 99384.

• For children age 18 (adolescent), use CPT code 99385.

For established patients making a well baby/well child care visits:

• For infants under age 1, use CPT code 99391.

• For children ages 1 to 4 (early childhood), use CPT code 99392.

• For children ages 5 to 11 (late childhood), use CPT code 99393.

• For children ages 12 to 17 (adolescent), use CPT code 99394.

• For children age 18 (adolescent), use CPT code 99395.

Preventive Medicine Visits


• Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare.

If you suspect a patient does not have coverage, advise him or her of your billing policies.

• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.

• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).

Patient and Visit Preventive


Medicine Code

New patient, initial visit Age 40 through 64 years 99386
Age 65 years and older 99387 Established patient, periodic visit
Age 40 through 64 years 99396 Age 65 years and older 99397

Preventive Medicine Services: Established Patients

Periodic comprehensive preventive medicine reevaluation and management of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures.


CPT Codes                        ICD-9-CM Codes

99391 Infant (younger than 1 year)           V20.31 Health supervision for newborn under 8 days old

                                             V20.32 Health supervision for newborns 8 to 28 days old

                                             V20.2 Routine infant or child health check

99392 Early childhood (age 1–4 years)        V20.2 Routine infant or child health check

99393 Late childhood (age 5–11 years)        V20.2 Routine infant or child health check

99394 Adolescent (age 12–17 years)           V20.2 Routine infant or child health check

99395 18 years or older                V70.0 Routine general medical examination  at a health care facility

OVERVIEW

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 pre  existing 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 the 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.existing 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 the 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.

Policy Statement

Preventive medicine services 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 diseaserelated diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the preventive visit, and significant elements of related E/M services are provided during the same visit. When this occurs, Medica will reimburse the preventive medicine E/M service at the contracted rate and the problem-oriented E/M service at 75% of the contracted rate, when appended with modifier 25.

Procedure codes used to bill preventive medicine services are:

** Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397

During a visit for a preventive medicine service, other services may be provided.

HealthWatch EPSDT codes PLUS Evaluation & Management (E&M) Codes PLUS Modifier 25* 

PLUS ICD-9 Diagnosis Codes 99381–99385or 99391–99395

The components of the EPSDT visit must be provided and documented.

99203–99215 The presenting problem must be of moderate to high severity Documentation  must support the use of a modifier 25

V20.2 must be the primary diagnosis code for the preventive visit Add multiple diagnosis codes for the presenting problem focused evaluation.

THE PREVENTIVE SERVICE E/M VISIT WITH A PROBLEM-ORIENTED SERVICE: AN EXAMPLE

A 52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, “Periodic comprehensive preventive medicine…, established patient; 40-64 years” and ICD-9 code V70.0, “Routine general medical examination at a health care facility”; and the problem-oriented code that describes the additional work associated with the evaluation of the respiratory complaints with modifier -25 attached, ICD-9 codes 466.0, “Acute bronchitis” and 786.50, “Chest pain” and the appropriate codes for the electrocardiogram and chest X-ray.

Bill Diagnosis code(s) V70.0

Routine exam Procedure code(s) 99396

Preventive service 466.0 786.50

Acute bronchitis  Chest pain 99213-25*

Office outpatient E/M service for established patient 93000

Electrocardiogram 71020

Chest X-ray, PA and lateral

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision-making.

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

Code 99420 is specific to administration and interpretation of health risk assessment instruments.

Payers may or may not allow use of this code for behavior-related questionnaires such as the Pediatric Symptom Checklist or one of the longer alcohol- or depression-related questionnaires.

Finally, the last of the preventive medicine codes is 99429, Unlisted Preventive Medicine Service. Practitioners are urged to check with the managed care plan or insurance carrier before using this code.

PREVENTIVE CODES THAT SHOULD GENERALLY BE COVERED AT NO OUT OF POCKET COST FOR BCBSIL HMO MEMBERS 


Preventive Medicine Services – Adult
Established Patient:
99394 – adolescent (12-17)
99395 – 18-39 years
99396 – 40-64 years
99397 – 65 years and older


Preventive Medicine Services – Pediatric
Established patient:
99391 – age younger than 1 year
99392 – age 1-4 years
99393 – age 5-11 years

NCCI Edit

99211 99212 99213 99214 99215 Mutually Exclusive   99391 99392 99393 99394 99395 99396 99397

Therefore, 99211-99215 is submitted with 99391-99397–only 99391-99397 reimburses.

Preventive Medicine Evaluation & Management (E&M) Services

 *  Preventive Medicine E&M services should be reported using the age appropriate code from the Preventive Medicine Services section of the most current CPT manual.

* Services rendered should be reported using 99381-99387 for new patients or 99391-99397 for established patients. These codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.

*  If an abnormality/ies is encountered, or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a  problem-oriented E&M service, then the appropriate  office/Outpatient code 99201-99215 should also be reported.

Modifier-25 should be added to the Office/Outpatient code to indicate that a significant; separately identifiable E&M service was provided by the same physician on the same day as the preventive medicine service. Note: An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” (AMA7)

“An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances…If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

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.

Screening Services

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When a screening code is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Prolonged Services

Prolonged services codes represent add-on services that are reimbursed when reported in addition to an appropriate primary service. Preventive medicine services are not designated as appropriate primary codes for the Prolonged services codes. When Prolonged service add-on codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Counseling Services

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Medical Nutrition Therapy Services

According to CPT, for Medical Nutrition Therapy assessment and/or intervention performed by a physician, report Evaluation and Management or Preventive Medicine service codes. When Medical Nutrition Therapy codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Visual Function and Visual Acuity Screening

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When Visual Function Screening or Visual Acuity Screening is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Preventive Medicine Service Provided at the Time of Covered Screening Service

A preventive medicine exam, as described by CPT-4 codes (99384 – 99397), includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.

The following are examples of screening services that are ineligible for separate reimbursement when reported with preventive medicine services, annual GYN examinations and/or problem oriented E/M services:

• G0101 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medicine services (99381-99397)

o annual GYN examinations (S0610, S0612, or S0613)

• G0102 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medicine services (99381-99397)

• Q0091 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medical services (99381-99397)*

o annual GYN examinations (S0610, S0612, or S0613)*

• S0610, S0612, and/or S0613 is included in the reimbursement for:

o preventive medicine services (99381-99397)

Coding for a Problem Focused Visit Within an EPSDT Visit

EPSDT codes

99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented

PLUS Evaluation and Management (E&M)codes

99203–99215 The presenting problem must be of moderate to high severity.

PLUS Modifier 25*

Documentation must support the use of modifier 25.

PLUS ICD-9 Diagnosis codes

V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation.

Effective 4/1/2014 EPSDT/Well Child visits are all-inclusive visits. The payment for the EPSDT is intended to cover all elements outlined in the AHCCCS EPSDT Periodicity Schedule (AMPM Exhibilt 430-1). Refer to AMPM Policy 430 for exceptions to the all-inclusive visit global payment rate. Claims must be submitted on CMS 1500 form. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventative medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier. EPSDT visits are paid at a global rate for the services specified in AMPM Policy 430. No additional reimbursement is allowed.

Providers must use an EP modifier to designate all services related to the EPSDT well child check-up, including routine vision and hearing screenings.

Providers must be registered as Vaccines for Children (VFC) Program providers and VFC vaccines must be used. Under the federal VFC program, providers are paid a capped fee for administration of vaccines to recipients 18 years old and younger. For VFC claims incurred prior to 1/1/2013, Providers must bill the appropriate CPT code for the immunization with the “SL” (State supplied vaccine) modifier that identifies the immunization as part of the VFC program.

Providers must not use the immunization administration CPT codes 90471, 90472, 90473, and 90474 when billing under the VFC program. Because the vaccine is made available to providers free of charge, providers must not bill for the vaccine itself.

For VFC services incurred on/after 1/1/2013, Section 1202 of the Patient Protection and Affordable Care Act (ACA) requires AHCCCS to modify how providers submit claims for vaccine administration services.