As a provider, you have likely found yourself in a scenario wherein you address an issue with your patient during a preventative/wellness visit. Sometimes, you can bill for preventative/wellness and evaluation/management (E/M) visits.
Understanding the nuances of billing in these scenarios helps you bill ethically and legally to receive the maximum compensation for services rendered. The team at Larsen Billing explores combining a preventative/wellness visit with a problem-focused E/M visit below. Read on to learn more.
Combined Billing According to Current Procedural Terminology (CPT®)
It is not uncommon for a patient to present for a preventative/wellness visit, and during the encounter, either the patient may bring up a problem that needs to be addressed, or the provider may identify something abnormal during the visit that warrants a further workup, thereby requiring care that goes beyond the preventative/wellness service.
The provider can often bill for preventative/wellness and problem visits (E/M) when this occurs.
According to the CPT® codebook created and maintained by the AMA:
If an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or 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.
CPT® does go on to clarify that “an insignificant or trivial problem/abnormality” identified during the visit but does not require additional workup should not be separately reported.
Modifier 25 should be appended to the office/outpatient code to bill for both services within the same encounter appropriately. Modifier 25 indicates that a significant, separately identifiable evaluation and management service was provided on the same day as the preventative/wellness service.
Providers should meticulously document their charts to distinguish between the two services. It’s best practice for the provider to create two separate encounter notes to identify the preventative/wellness and problem-focused visit.
Determining the Appropriate Level of Service for the Problem-Visit E/M
The level of service for the problem-visit E/M may be based on time or medical decision-making (MDM). We review both levels below.
Level of Service Based on Time
For cases in which a problem visit is being reported during the same encounter as the preventative/wellness visit, coding based on time may be slightly more complicated; the provider must ensure they are only considering the time spent addressing the problem and not time spent on the preventative/wellness service.
For coding purposes, time is the total time that includes both face-to-face time and non-face-to-face time on the day of the encounter.
Included in Total Time
The following elements should be included in the total time:
- Preparing to see the patient (e.g., reviewing external test results)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient, family, or caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health records
- Independently interpreting results (not separately reported with a CPT® code) and communicating results to the patient, family, or caregiver
- Care coordination (not separately reported with a CPT® code)
Not Included in Total Time
These elements are not included in the total time:
- Performance of other services that are reported separately
- Travel
- Teaching that is general and not limited to the discussion that is required for the management of a specific patient
You can find time codes for both new and established patients in the charts below:
| New Patient | Time (minutes) |
| 99202 | 15-29 |
| 99203 | 30-44 |
| 99204 | 45-59 |
| 99205 | 60-74 |
| Established Patient | Time (minutes) |
| 99212 | 10-19 |
| 99213 | 20-29 |
| 99214 | 30-39 |
| 99215 | 40-54 |
Prolonged Visit Codes
When the total time on the date of service extends beyond the times listed above for codes 99205 and 99215 by at least 15 minutes, a prolonged service code may be added, and it can be billed in 15-minute increments.
| Prolonged Service Code | Definition | |
| CPT® | 99417 | Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. |
| HCPCS (CMS) | G2212 | Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure, which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. |
Level of Service Based on Medical Decision-Making (MDM)
The three elements of MDM include:
- The number and complexity of problems addressed during the encounter
- The amount and/or complexity of data reviewed or analyzed
- Data would include information that must be reviewed, obtained, ordered, and analyzed for the encounter
- The risk of complications and/or morbidity or mortality of the patient management
The levels of MDM are categorized into four types:
- Straightforward
- Low complexity
- Moderate complexity
- High complexity
The chart below delineates the level of service based on MDM:
| MDM Level | Number and complexity of problems addressed | Amount and/or complexity of data to be reviewed or analyzed
|
Risk of complications and/or morbidity or mortality of the patient management |
| Straightforward | Minimal | Minimal or none | Minimal |
| Low | Low | Limited | Low |
| Moderate | Moderate | Moderate | Moderate |
| High | High | Extensive | High |
Two out of three elements from the table must be met or exceeded to determine a level of service for an encounter.
For example, a provider may address multiple problems during a visit; however, there is limited data, and the risk is low. In this scenario, the medical decision-making level would qualify as low.
The following table below breaks down the number and complexity of problems addressed:
| 99202/99212 | Minimal | One self-limited or minor problem |
| 99203/99213 | Low | Two or more self-limited or minor problems or one stable, chronic illness or one acute, uncomplicated illness or injury |
| 99204/99214 | Moderate | One or more chronic illnesses with exacerbation, progression, or side effects or treatment; or two or more stable, chronic illnesses; one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms, or one acute uncomplicated injury |
| 99205/99215 | High | One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function |
Preventative Service Codes
Preventative medicine services have unique codes based on the patient’s age and status as either new or established. We include these codes in the chart below:
Preventative Medicine Services
| Age | New Patient | Established Patient |
| Younger than 1 year | 99381 | 99391 |
| 1-4 years | 99382 | 99392 |
| 5-11 years | 99383 | 99393 |
| 12-17 years | 99384 | 99394 |
| 18-39 years | 99385 | 99395 |
| 40-64 years | 99386 | 99396 |
Additionally, Medicare employs a unique code set for preventative services. When billing Medicare for preventative care, enter the appropriate codes found below:
Preventative Services for Medicare
| Initial preventive physical examination (IPPE); services limited to new beneficiaries during the first 12 months of Medicare enrollment | G0402 |
| Annual wellness visit; includes a personalized prevention plan of service (PPS), an initial visit | G0438 |
| Annual wellness visit includes a personalized prevention plan of service (PPS), subsequent visit | G0439 |
Billing Made Simple
Accurate coding and billing are essential for your practice to receive appropriate payments based on services rendered. Understanding when and how to combine a preventative/wellness visit with a problem-focused E/M visit ensures you optimize your time and talents to receive the highest payment possible.
However, we at Larsen Billing know the time and energy commitment required to execute accurate medical billing and coding practices. If you’re busy caring for patients, neither you nor your team have the time or resources to spend countless hours on coding, billing, and claims manage ent. That’s why we are here.
Larsen Billing provides medical billing and coding services that keep your practice running, ensuring on-time and accurate submissions that reduce claims denials and the highest payment possible. Our team of experts studies coding and regulation updates to keep your practice compliant with every claim submission.
Learn how Larsen Billing can help you focus on patient care while we handle your billing, claims, and compliance n eds. Our team cares about your success and works to that end every step of the way.