Can You Bill a Preventive Visit With an Office Visit?
Understand the precise guidelines for billing both preventive and problem-focused medical visits on the same day.
It is possible to bill for both a preventive visit and a problem-oriented office visit on the same day. This practice can accurately reflect the comprehensive care provided to a patient during a single encounter, provided specific billing rules and thorough documentation are followed.
Defining Preventive Care
Preventive care visits focus on maintaining health, identifying potential health risks, and detecting conditions early. These appointments aim to prevent illness or injury through proactive measures. Typical services include age-appropriate screenings, risk assessments, and counseling on health topics like diet, exercise, and vaccinations.
An Annual Wellness Visit (AWV) for Medicare beneficiaries, for example, focuses on developing or updating a personalized prevention plan. This visit may include routine measurements, a review of medical and family history, medication review, and personalized health advice. An AWV is distinct from a comprehensive physical exam and does not typically involve diagnosing or treating a specific illness. CPT codes for preventive medicine services for established patients range from 99391-99397.
Defining Problem-Oriented Care
Problem-oriented care, an Evaluation and Management (E/M) office visit, focuses on diagnosing and treating new or existing health issues, managing chronic conditions, or addressing acute illnesses. These visits are driven by a patient’s specific symptoms or complaints. Their goal is to evaluate, monitor, and manage conditions requiring direct medical intervention.
Examples include evaluating a new rash, managing uncontrolled diabetes, or addressing acute respiratory symptoms. These visits involve a history, focused examination, and medical decision-making to develop or adjust a treatment plan. CPT codes for office or outpatient E/M services fall within the 99202-99205 range for new patients and 99211-99215 for established patients.
Billing for Both Services on the Same Day
Billing for both a preventive service and a problem-oriented service on the same day is permissible when the problem-oriented service is “significant and separately identifiable” from the preventive service. This means the work performed for the acute or chronic condition must go beyond the typical components of a routine preventive exam and be medically necessary. CPT guidelines clarify that if an abnormality or pre-existing problem is addressed during a preventive visit, and it requires additional work for a problem-focused E/M service, then both services can be billed.
For example, if a patient presents for an annual preventive visit and also reports new symptoms like persistent knee pain that require a separate, in-depth assessment and management plan, billing both services is appropriate. The medical necessity for the problem-oriented service must be clearly documented, demonstrating that the provider’s work addressed a specific illness or injury. Minor issues such as routine prescription refills or brief discussions about mild symptoms that do not require substantial additional work should not trigger a separate E/M service.
Documentation and Coding for Concurrent Services
Accurate documentation is paramount when billing for both preventive and problem-oriented services on the same day. The medical record must clearly delineate the work performed for each service, demonstrating that the problem-oriented service was distinct and medically necessary. This includes separate documentation of the history, examination, and medical decision-making pertaining to the specific problem addressed, ensuring the work for the problem-oriented visit goes beyond the standard components of the preventive visit. While separate notes are not always required, physically separating the documentation for each service within the patient’s record can aid in clarity and support.
For coding these concurrent services, Modifier 25 is essential. Modifier 25, defined as “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service,” is appended to the Evaluation and Management (E/M) code. This modifier indicates that the E/M service was significant and distinct from the preventive service performed on the same day. For instance, if a patient receives an annual wellness visit (e.g., CPT code 99396) and also has a significant, separately identifiable problem addressed (e.g., CPT code 99213), the E/M code 99213 would be reported with Modifier 25 (99213-25). It is important to remember that Modifier 25 should only be used when the E/M service is truly significant and goes above and beyond the usual work associated with the preventive service.