When patients schedule preventive or wellness visits, it’s common for physicians to also address acute or chronic health issues during the same appointment. This often leads to confusion about proper coding and billing practices for both preventive and problem-focused evaluation and management (E/M) services. Many believe that billing for both is not allowed, or that only one service will be reimbursed, leading to billing errors and patient misunderstandings.
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Debunking the Myth: Billing for Preventive and Problem-Focused E/M Services
It is a myth that physicians cannot bill for both preventive and problem-focused E/M services when provided during the same patient encounter. In fact, billing for both is often appropriate and justified. The key to correct coding lies in understanding the complexity of the medical issues addressed and the level of medical decision-making involved. Accurate and comprehensive documentation of all medically necessary care is essential for proper billing. Under-coding, often driven by fear of audits, can result in significant revenue loss for practices.
Regulatory Clarification: CPT® Guidelines and Modifier 25
The Current Procedural Terminology (CPT®) guidelines offer clear direction on this matter. If, during a preventive visit, a significant abnormality or pre-existing condition is identified and requires additional evaluation and management beyond the scope of the preventive service, then a separate office/outpatient E/M code should also be reported. To accurately reflect that a significant and separately identifiable E/M service was performed alongside the preventive service on the same day, Modifier 25 must be appended to the office/outpatient E/M code. The preventive medicine service is reported in addition to the E/M service.
Conversely, if the identified problem or abnormality is minor or insignificant, requiring minimal additional work and not necessitating the key components of a problem-focused E/M service, then a separate E/M code should not be billed.
Billing Medicare and Commercial Payers
When it comes to Medicare billing, the Centers for Medicare & Medicaid Services (CMS) mandates separate billing for qualifying E/M services performed in conjunction with preventive services. According to the CMS website, “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay for the additional service. Report the additional CPT code with Modifier-25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part.”
For commercial payers, coverage policies can vary depending on the specific patient plan. Some commercial payers may reimburse for a separate problem-focused E/M service billed during the same visit as a preventive service, while others may not. Regardless of payer type (commercial or Medicare), correct application of Modifier 25 is crucial for accurate claims processing and reimbursement for eligible services.
Patient Communication and Financial Responsibility
Billing for additional E/M codes can impact a patient’s out-of-pocket expenses. Open communication with patients about the potential for these additional charges during preventive visits is highly recommended. Discussing this possibility upfront can help manage patient expectations and prevent confusion or dissatisfaction related to unexpected medical bills. Furthermore, ensuring that practice billing staff are well-versed in payer-specific policies is essential to minimize the risk of unanticipated charges and billing errors.
Earn CME Credit for Debunking Regulatory Myths
Interested in expanding your knowledge and earning Continuing Medical Education (CME) credits? The AMA Ed Hub™ offers a module on debunking regulatory myths, providing valuable insights into compliant coding and billing practices.
Resources for E/M Coding and Preventive Care Visits
For further information and resources on E/M coding, preventive care visits, and related regulatory guidelines, refer to the following:
AMA Policy on Preventive and Problem-Focused E/M Services
References for Coding and Billing Guidelines
Debunking Regulatory Myths Overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA’s Debunking Regulatory Myths (DRM) series provides general information based on regulatory agency guidance and is not intended as legal advice. Consult with a legal professional for specific legal counsel. Always consider all applicable laws and accreditation standards for your practice.
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Last reviewed in March 2022.
