CPT code and Description
99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes N Y Category 2
99412 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes
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.
Reasons for Denial
1. Beneficiaries who do not have specific underlining medical condition.
2. Services for preventive medicine counseling and/or risk factor reduction intervention.
3. Services to beneficiaries who require psychiatric services (services should be billed with CPT codes 90801 – 90899).
4. Evaluation and Management services, including Preventive Medicine, Individual Counseling codes 99401 – 99404, and Preventive Medicine, Group Counseling codes 99411 – 99412 billed on the same day as 96150 – 96154.
Questions and Answers
Q: Why does UnitedHealthcare reduce reimbursement to 50% for an E/M service (99201-99205 or 99411-99412 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine Service?
A: UnitedHealthcare 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 (E/M). 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.
