Q: If a patient is new and you bill the new preventive patient code, should you also bill a new evaluation and management (E/M) with modifier 25 if a significant separate issue warrants the billing of the E/M? Or would the added E/M visit be billed as established?
A: This is a situation that practices come across all the time. When a preventive medicine visit (CPT codes 99381-99397) is billed in addition to an Evaluation and Management (E/M) code, the E/M code would be billed as an established patient visit (99211-99215). Let’s explore this step by step to understand why this is the case.
First, all elements that are normally performed during a preventive exam are counted towards the preventive visit. These elements include most of the Past, Family and Social History, the Exam, and the portions of the Assessment/Plan (A/P) that pertain to preventive medicine (i.e., labs, orders for mammograms, colonoscopies, etc.)
Therefore, the only elements that can be counted towards the E/M code are the History of Present Illness (HPI), Review of Systems (ROS), and pertinent parts of Past, Family and Social history (PFSH), substantial additional work performed in the exam, and the elements in the A/P that detail the medical significant work/management of problems.
I have found that during preventive visits, exam elements normally are not documented for the medical issues presented by the patient. Therefore, only the history and A/P elements can be counted toward the E/M code, which would only support an established-patient E/M code.
It is also true that insurance carriers will typically not pay for two new-patient visits on the same date of service.