cpt preventive visit

It’s not hard, once you get the hang of it, but the differences from E/M coding can be confusing.

TIMOTHY OWOLABI, MD, CPC, AND ISAC SIMPSON, DO

Fam Pract Manag. 2012;19(4):12-16

Dr. Owolabi is a board-certified family physician and certified professional coder employed by Summit Physician Services, a multispecialty, hospital-owned group practice in Chambersburg, Pa. In addition to managing a busy patient panel, Dr. Owolabi independently offers coding consulting services and speaks and writes on coding topics. Dr. Simpson is a family medicine resident at Phoenix Baptist Hospital Family Medicine Residency in Phoenix, Ariz. Author disclosure: no relevant financial affiliations disclosed.

This is a corrected version of the article previously published.

In our experience, family physicians vary widely in their understanding of preventive care coding. Questions we’ve heard range from “What ICD-9 codes are appropriate with preventive care visits?” all the way down to “Preventive codes? What are preventive codes? I only use evaluation and management [E/M] codes.” No matter what your level of comfort (or discomfort) with coding preventive visits, we hope to offer information you’ll find useful. We will define the documentation components necessary to code preventive visits for patients 18 to 64 years old, review the appropriate ICD-9 and CPT codes and how to properly pair them, and discuss the proper use of modifier 25. We won’t cover the Medicare guidelines for preventive visits or how to code pediatric preventive visits. Coding resources for these visits are listed below.

Components of a preventive visit

Preventive visits, like many procedural services, are bundled services. Unlike documenting problem-oriented E/M office visits (99201–99215), which involves complicated coding guidelines, documenting preventive visits is more straightforward. The following components are needed:

A comprehensive history and physical exam findings;

A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT;

Notes concerning the management of minor problems that do not require additional work;

Notes concerning age-appropriate counseling, screening labs, and tests;

Orders for vaccines appropriate for age and risk factors.

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. Rather, it requires a “comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.” The preventive comprehensive exam differs from a problem-oriented comprehensive exam because its components are based on age and risk factors rather than a presenting problem.

Some have attempted to use modifier 52 to denote reduced services when less than a comprehensive history and exam are performed during a preventive visit. This is inappropriate because modifier 52 applies to procedural services only. Preventive visits that do not satisfy the minimum requirements may be billed with the appropriate E/M office visit code.

When submitting a preventive visit CPT code, it is not appropriate to submit problem-oriented ICD-9 codes. Linking problem-oriented ICD-9 codes with preventive CPT codes may delay payment or result in a denied claim. See “ Acceptable codes for preventive care visits ” for the appropriate ICD-9 codes and the HCPCS and CPT codes with which to pair them.

Coverage of preventive visits varies by insurer, so it is important to be aware of the patient’s health plan. Most plans limit the frequency of the preventive visit to once a year, and not all tests are covered. Fecal occult blood tests, audiometry, Pap smear collection, and vaccines and their administration should be billed separately. Visual acuity testing is not separately reimbursed. Without a new or chronic-disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-9 code for screening should be assigned on the order form and claim.

Another service that has a preventive purpose is the preoperative clearance. Review of the details of this encounter is beyond the scope of this discussion, but it is worth mentioning that many private payers cover the preoperative clearance when billed by primary care physicians using consultation E/M codes (99241-99255).

ACCEPTABLE CODES FOR PREVENTIVE CARE VISITS

Preventive visits and the role of counseling.

Preventive visit codes 99381-99397 include “counseling/anticipatory guidance/risk factor reduction interventions,” according to CPT. However, when such counseling is provided as part of a separate problem-oriented encounter, it may be billed using preventive medicine codes 99401-99409. For example, if you provide significant counseling on smoking cessation during a visit for an ankle sprain, you could bill for the counseling in addition to submitting an E/M office visit code for the problem-oriented service. A synopsis of the counseling should be included in your documentation, and ICD-9 codes for preventive counseling should be paired with your CPT codes (see “ Acceptable codes for preventive counseling services ”). Such a visit requires the use of modifier 25.

ACCEPTABLE CODES FOR PREVENTIVE COUNSELING SERVICES

Modifier 25.

When providing a preventive visit with a problem-oriented E/M service or procedural service on the same day, including modifier 25 in your coding may enable you to be paid for both services. CPT says modifier 25 is appropriate when there is a “significant, separately identifiable evaluation and management service by the same physician on the same day.” Stated another way, if the second service requires enough additional work that it could stand on its own as an office visit, use modifier 25. Modifier 25 should usually be attached to the problem-oriented E/M code. However, if the second service is a procedure, such as removal of a skin lesion performed in conjunction with a preventive visit, the modifier should be attached to the preventive visit code because it is the E/M service.

Having a separate note for the second service can greatly decrease the likelihood of having it inappropriately bundled or denied. Note that no one item of documentation can count toward both services. A problem-oriented E/M service that requires a considerable amount of work and pertinent documentation may absorb so many of the elements that would otherwise count toward the preventive service that you don’t have a comprehensive history and exam for the preventive service. This is one reason some doctors provide two visits in these situations.

Bundling is more likely if the separate service can be considered age-appropriate, such as initiating treatment for acne. However, if a separate E/M note can be written for the problem, the CPT description of modifier 25 and the exclusions listed for the preventive visit CPT codes indicate that the separate service should not be bundled. See “ Appropriate use of modifier 25 during a preventive visit ” for examples of complaints that under some circumstances would be handled as part of a preventive visit, but under different circumstances may require additional work that should be billed separately using modifier 25.

Unfortunately, not all carriers pay for services billed with modifier 25. For example, Aetna did not reimburse at all for modifier 25 until 2006, when it changed its policy as part of a class action settlement with multiple state medical societies. The circumstances in which its use is permitted and the amount of payment for the separate service vary. The lack of consensus on the use of modifier 25 for preventive services places the onus on providers to learn the requirements of each of their payers.

APPROPRIATE USE OF MODIFIER 25 DURING A PREVENTIVE VISIT

Preventive care and productivity.

Discussing the cost-effectiveness of preventive visits for the practice is tricky because of the number of variables to consider. Time spent per preventive visit is a key confounding variable. Others include fee schedule variations between payers, payer mix, productivity variations between physicians, which preventive service is being considered (for patients in the 18–39 age group vs. those in the 40–64 age group or new vs. established), and accuracy of coding, to mention a few.

While the numerous variables make broad generalizations about the immediate cost-effectiveness of preventive visits extremely difficult, careful analysis may lead some practices to conclude that preventive care is beneficial not only for the patient but for the practice as well. As an example, we averaged payment for two visit types from nine actual payers. The visits we considered were a 40-year-old established-patient preventive visit (CPT 99396), minus immunizations and other separate charges, and a level-4, established-patient, problem-oriented visit (CPT 99214). We found the average payment for the preventive visit to be 25 percent higher than for the problem-oriented visit. That is, the preventive visit produces more revenue per unit of time unless the preventive visit takes at least 25 percent longer. Of course, if a preventive visit requires considerably more time than a comparable level-3 or level-4 E/M visit, replacing preventive visits with a larger number of problem-oriented visits could result in more reimbursement overall, at least in theory.

Role of preventive services in our health care system

Some researchers estimate that 75 percent of all health care costs are due directly to preventable chronic conditions, yet as recently as 2004, only 1 percent of money spent on health care in the United States was devoted to prevention. 1 , 2 We don’t wish to spark a debate on whether preventive services directly reduce health care costs, but we speculate that preventive care has the potential to play a more valuable role in our health care system than it does currently. The Centers for Medicare & Medicaid Services did not cover preventive care visits until the institution of the “Welcome to Medicare” visit in 2005. In contrast, many private payers have covered preventive visits for some time. Perhaps this is because they have long recognized that healthy lifestyle choices and routine health surveillance mitigate the risk of chronic disease.

PREVENTIVE VISIT ALGORITHM: PATIENTS AGES 18–64*

Regardless of insurance coverage, patients should at least be offered preventive services even if they must pay out of pocket for them. The “ Preventive visit algorithm ” illustrates how one might approach a preventive visit for a patient in the 18 to 64 age range (except for recommended pregnancy-related services). This schematic is not intended to reflect all the anticipatory guidance or all of the screening that you might recommend for a given patient, but rather includes suggestions based on the strongest evidence-based recommendations from the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force.

ADDITIONAL RESOURCES FOR CODING PREVENTIVE CARE

Coding for Pediatric Preventive Care 2012 . American Academy of Pediatrics.

What You Need to Know About the Medicare Preventive Services Expansion . FPM . Jan/Feb 2011.

Making Sense of Preventive Medicine Coding . FPM . Apr 2004.

Medicare Preventive Services: Quick Reference . Centers for Medicare & Medicaid Services.

Center for Medicare & Medicaid Services National Health Expenditures and Selected Economic Indicators, Levels and Average Annual Percent Change: Selected Calendar Years 1990–2013 Washington, DC: Center for Medicare & Medicaid Services, Office of the Actuary; 2004.

Institute of Medicine The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy Press; 2002.

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Healthcare Insights

Top 10 preventive medicine CPT codes

Published Feb 20th, 2023

Preventive medicine is a type of medicine that protects patients and communities from avoidable disability, illness, and death. Healthcare providers offer testing, counseling, and immunizations to prevent illness and identify potential health concerns as they emerge.

Preventive medicine is a vital component of healthcare because it promotes overall wellness, reduces the occurrence of illness, and saves resources.

Using data from the Atlas All-Payor Claims Database , we compiled a list of the top 10 preventive medicine CPT codes below.

Fig. 1 Data is from the Definitive Healthcare Atlas All-Payor Claims Database and represents procedure claims for January – December 2022. Data is accurate as of February 2023.

What was the top preventive medicine CPT code in 2022?

The top preventive medicine CPT code was 99396, a preventive visit for an established patient between ages 40 and 64, representing over 20% of all preventive medicine claims and nearly a quarter of total charges in 2022.

The 40-64 age group is particularly susceptible to conditions like breast cancer, colon cancer, and osteoporosis. Preventive services are especially valuable to patients who face greater risk of illness, whether due to age, comorbidities, lifestyle, or other factors.

The table above also indicates that nearly 80% of preventive medicine claims were for established patients versus new patients. This breakdown shows that most preventive medicine services are for patients who have already received care from the provider.

Why do many people forgo preventive care?

Without health insurance , medical care can be costly and difficult to navigate. For this reason, individuals who do not have health insurance often forgo preventive care. A Bankrate survey found that in 2020, 32% of families in the U.S. did not seek medical care in the past 12 months due to cost.

A study from the CDC found four influencers of preventive care . First, and most prominently, was finances, followed by the use of metrics driving change in the healthcare system, and the role of healthcare payors . The final influencing factor was changes in healthcare reimbursement models.

Individuals who do not receive preventive care are at increased risk for disabilities, diseases, and death .

What is a CPT code?

The Current Procedural Terminology (CPT) is a system of codes used for reporting healthcare services and medical procedures. CPT codes increase the efficiency and accuracy of healthcare reporting and billing.

Definitive Healthcare tracks many CPT codes across diagnostic, medical, and surgical areas. This information can give you insight into diagnosis, procedure, and prescribing activity and transform your sales and marketing strategies.

Learn more

To hear more about the long-term implications of pandemic-related delays in care, including preventive care, listen to our podcast with Dr. Mark Pimentel .

Healthcare Insights are developed with  healthcare commercial intelligence  from the Definitive Healthcare platform. Want even more insights? Start a  free trial  now and get access to the latest healthcare commercial intelligence on hospitals, physicians, and other healthcare providers.

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• Top 10 Preventive Medicine CPT Codes

CPT CODE 99381, 99382 – 99385 – Preventive visit new patient

Sep 25, 2016 | Medical billing basics

CPT Code and description

99381 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)

99382 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years)

99383 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) – Average fee amount $110 – $130

99384 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Average fee amount $120 – $140

99385 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years  –  Average fee amount – $120 – $ 150

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397 , Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse  Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

For a list of specific codes that are included in (and not separately reimbursed from) Preventive Medicine Services see the Applicable Codes section below.

For the purposes of this policy, Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is defined as a physician, hospital, ambulatory surgical center, and/or other health care professional of the same group and Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional reporting the same Federal Tax Identification number.

PREVENTIVE MEDICINE SERVICES, NEW PATIENT

Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for a new patient.

Code Description

99381 Infant (age under 1 year) 99382 Early childhood (ages 1 through 4 years) 99383 Late childhood (ages 5 through 11 years) 99384 Adolescent (ages 12 through 17 years) 99385 18–39 years 99386 40–64 years 99387 65 years and over

PREVENTIVE MEDICINE SERVICES, ESTABLISHED PATIENT

Periodic comprehensive preventive medicine re-evaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for an established patient.

Code Description 99391 Infant (age under 1 year) 99392 Early childhood (ages 1 through 4 years) 99393 Late childhood (ages 5 through 11 years) 99394 Adolescent (ages 12 through 17 years) 99395 18–39 years 99396 40–64 years 99397 65 years and over

New versus Established client: A new client is defined as one who has not received any professional services from a physician/qualified health care professional in your health department, within the last three years, for a billable visit that includes some level of evaluation and management (E/M) service coded as a preventive service using 99381-99387 or 99391-99397, or as an evaluation & management service using 99201-99205 and 99211-99215. If the client’s only visit to the Health Department is WIC or immunizations without one of the above service codes, it does not affect the designation of the client as a new client; the client can still be NEW. Remember that a client may be new to a program but established to the health department if they have received any  professional services from a physician/qualified health care professional.

In this case, you would use the forms for a “new” patient for that program even though the client is billed as “established” to the health department. Due to National Correct Coding Initiative (NCCI) edits the practice of billing a 99211, and then later billing a new visit code, has been eliminated. Many LHDs have been billing a 99211 (usually an RN only visit) the first time they see a patient and then, up to 3 years later, bills a 99201 – 99205 or 99381-99387 (New Visit). Examples may include: billing the 99211 for pregnancy test counseling or head lice check by RN and then a new visit when the patient comes in for their first prenatal, Family Planning or Child Health visit. Now that the NCCI edits have been implemented, all of those “new” visits will deny because the LHD will have told the system (via billing a 99211) that the patient is “established.” Consult your PHNPDU Nursing Consultant if you have questions.

ADULT PREVENTIVE CARE PROCEDURE CODES

Code Description 76091 Mammogram (specialty center) 82270 Fecal Occult Blood Test (lab procedure code only) 82465 Total Serum Cholesterol (lab procedure code only) 84153 PSA (lab procedure code only) 86580 Tuberculosis (TB) Screening (PPD) 88150 Pap Smear (lab procedure code only) 90658 Flu Shot 90718 Td-Diphtheria–Tetanus Toxoid–0.5 ml 90732 Pneumovax

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.

QUESTIONS AND ANSWERS 1 Q: Why does Oxford reduce reimbursement to 50% for an evaluation and management (E/M) service (99201-99205 or 99212-99215 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine service ?

A: Oxford 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 (evaluation and management). 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.

2 Q: In what situation is CPT code 96110 reimbursable?

A: As defined, CPT code 96110 represents developmental screening with interpretation and report. In the introduction to the section in which this code appears, the CPT book states that “it is expected that the administration of these tests will generate material that will be formulated into a report.” Because a physician obtains developmental information as an intrinsic part of a preventive medicine service for an infant or child and because this information is sometimes obtained in the form of a questionnaire completed by the parents, it is expected that this code will be reported in addition to the preventive medicine visit only if the screening meets the code description. Physicians should report CPT code,  for developmental screening or other similar screening or testing, separate and distinct from the Preventive medicine service only when the testing or screening results in an interpretation and report by the physician being entered into the medical record.

3 Q: Why is Q0091 not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers Q0091 (obtaining, preparing and conveying a cervical or vaginal smear to the laboratory) to be an integral part of a Preventive Health Care service. Therefore, this component of a Preventive visit is not separately reimbursable.

4 Q: Why is 99173 (screening test of visual acuity) not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers vision screening using an eye chart to be integral to a Preventive Medicine examination in the same way that measurements of height, weight and blood pressure are integral to a Preventive Medicine examination. Therefore, vision screening using an eye chart is not reimbursed separately from a Preventive Medicine examination.

5 Q: Why is 99172 (visual function screening) not separately reimbursable when billed with a Preventive Medicine code?

A: The CPT Book clearly states that this service should not be reported in addition to an E/M code.

6 Q: How does Oxford reimburse for screening tests based on a questionnaire completed by the patient or a family member when done in conjunction with a Preventive Medicine service?

A: Counseling, anticipatory guidance and risk factor reduction interventions are integral to a Preventive Medicine visit. Historical information may be obtained either through direct questioning or through completion of a written questionnaire. The responses on a questionnaire often identify areas for more focused interventions or treatments. Since this screening is part of a Preventive Medicine service, it is not reimbursed separately. Occasionally, a screening instrument requires interpretation, scoring, and the development of a report separate from the Preventive Medicine encounter. In those  situations, where a CPT code exists for that service, screening, interpretation and development of a report is reimbursed separately from a Preventive Medicine service. State Exceptions

Arizona Per Arizona State Regulations, effective 4/1/14 claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form for members up to age 21. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier.

EPSDT visits are paid at a global rate for the services specified and no additional reimbursement is allowed. Providers must use an EP modifier to designate all services related to the EPSDT well child check-ups, including  routine vision and hearing screenings.

* A list of preventative, office or other outpatient services that are considered included in the global payment of the preventive medicine CPT code is attached to this policy

*  Ocular photoscreening with interpretation and report, bilateral (CPT code 99174) is allowed for members under age 19. Arizona EPSDT Bundled Codes Lis t

A list of preventative, office or other outpatient services that are considered included in the global payment for the preventive medicine CPT codes (99381 – 99385, 99391 – 99395).

DC EPSDT Well-Child Visit Billing Reference Guide

When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include:

* Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders

* Comprehensive, unclothed physical examination

* Appropriate immunizations (as established by ACIP)

* Laboratory testing (including blood lead screening appropriate for age and risk factors)

* Health education and anticipatory guidance for both the child and the caregiver.i

To bill for a well-child visit:

* Use the age-based CPT code (99381-99385; 99391-99395). See Table 1.

o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code

* Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.

* If a screening or assessment is positive and requires follow-up or a referral, please use modifier TS with the applicable screening code that had a positive result.

DO NOT USE THE E&M OUTPATIENT VISIT CODES (99201-99205; 99213-99215) TO BILL FOR A WELLCHILD VISIT.

Table1: Age Based Preventive Visit CPT Codes Table 2: Screening/Assessment CPT Codes Patient’s Age                CPT Code           Dx Code

< 1 year  99381/91  new/established  V20.31,  20.32,  V20.2

1 – 4 years 99382/92 V20.2

5 – 11 years 99383/93 V20.2

12 – 17 years 99384/94 V20.2

18 – 21 years 99385/95 V70.0

HCY/EPSDT Billing Codes [1][2][3] AGE CPT Code: New Patient AGE CPT Code:

Established Patient Modifiers As Applicable ICD-10-CM Diagnosis Codes Preventive visit, Modifier EP: Used with procedure codes 99381-99385 and 99391-99395 when a Full or Partial screening is performed.

Modifier 52: Used with modifier EP when all components have not been met, but at least the first 5 or more components were completed according to the HCY/EPSDT requirements.

Modifier 59: Used when only components related to developmental and mental health are screened.

Modifier 25: Used on the significant, separately identifiable problem-oriented evaluation and management service when it is provided on (1) the same day as the preventive medicine service and/or (2) with administration of immunizations. Please note that modifier 25 is not to be used on preventive codes and needs to be billed using office or outpatient codes (99201-99215), and that these screenings bundle administration of immunizations.*Documentation must support the use of a modifier 25. See MO HealthNet Provider Manual. Modifier UC: Used when a referral is made for further care.

Z00.110 Newborn under 8 days old

Z00.111 Newborns 8 to 28 days old or

Z00.121 Routine child health exam with abnormal findings

Z00.129 Routine child health exam without abnormal findings Preventive visit, 1-4

99382 Preventive visit, 1-4

99392 Z00.121 Z00.129 Preventive visit, 5-11

99383 Preventive visit, 5-11

99393 Z00.121 Z00.129 Preventive visit, 12-17

99384 Preventive visit, 12-17

99394 Z00.121 Z00.129 Preventive visit, 18 or older

99385 Preventive visit, 18 or older

99395 Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings

NCCI Edit with preventive visits

National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation & Management (E&M) Codes Effective April 1, 2014, the Department will no longer reimburse NCCI procedure-to-procedure (PTP)  edits when immunization administration procedure codes (CPT 90460-90474) are paired with preventative medicine E&M service procedure codes (CPT 99381-99397).

If a significant separately identifiable E&M service (e.g. new or established patient office or other outpatient services [99201-99215], office or other outpatient consultation [99241-99245], emergency department service [99281-99285], preventative medicine service [99381-99429] is performed), the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI  PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an editunder appropriate circumstances. A modifier indicator of “9” indicates that the edit has been deleted, and the modifier indicator is not relevant. The Correct Coding Modifier Indicator can be found in the files containing Medicaid NCCI PTP edits on the CMS website.

A modifier should not be added to a HCPCS/CPT code solely to bypass an NCCI PTP edit, if the clinical circumstances do not justify its use. If the E&M service is significant and separately identifiable and performed on the same day, the E&M code should be billed with the vaccine and toxoid administration codes using PTP associated modifier ‘25’. Modifier ‘25’ is only valid when appended to the E&M codes. Do not append to the immunization administration procedure codes 90460-90474.

Therapeutic Injections Office visits (CPT codes 99201-99205; 99212-99215; 99381-99397) will not be separately reimbursed when submitted with therapeutic injections (CPT code 96372). Please append Modifier 25 to the disallowed E/M code if a significant separately identifiable E/M service was performed. Note: CPT code 96372 has been valued to include the work and practice expenses of CPT code 99211. A modifier will not override this edit.

Visual Acuity Testing CPT code 99173, visual acuity screening test, is separately reimbursable when submitted with preventive office visits (CPT codes 99381-99397). Vital Capacity Vital capacity (CPT code 94150) is considered incidental to the overall service provided, whether an office visit or a procedure, and will not be separately reimbursed.

Payment guidelines

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling,  anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a  preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same  visit. When this occurs, Oxford will reimburse thePreventive Medicine service plus 50% the Problem-Oriented E/M  service code when that code is appended with modifier  25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes. Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes. Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes. Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

Reporting Evaluation and Management Services With Immunizations

E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits ( CPT 99201 –99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.

The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.

• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.

• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not  be reported when the patient encounter is for vaccination only because the Medicare Resource-BasedRelative Value Scale (RBRVS) relative values for the immunization administration codes incl de administrative and clinical services (ie, greeting the patient, routine  vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine questions, preparation and administration of the vaccine, and  documentation and observation of the patient following the administration of the vaccine). However, if the service is medically necessary, significant, and separately  identifiable, it may be reported with modifier 25 appended to the E/M code (99211). Note that the medical record must clearly state the reason for the visit, brief  history, physical examination, assessment and plan, and any other counseling or discussion items. The progress note must be signed with the physician’s  countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during immunization administration, visit  www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers who do not follow the Medicare RBRVS  may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make certain that the guidelines are in  writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.

• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.

• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

• Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.

Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive

medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

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All the contents and articles are based on our search and taken from various resources and our knowledge in Medical billing. All the information are educational purpose only and we are not guarantee of accuracy of information. Before implement anything please do your own research. If you feel some of our contents are misused please mail us at medicalbilling4u at gmail dot com. We will response ASAP.

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List of CPT/HCPCS Codes

We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. We update the Code List to conform to the most recent publications of CPT and HCPCS codes and to account for changes in Medicare coverage and payment policies. Code List updates for years 2022 and earlier were published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. 

Beginning with the Code List effective January 1, 2023, updates are published solely on this webpage.  On or before December 2 nd of each year, we will publish the annual update to the Code List and provide a 30-day public comment period using www.regulations.gov . To be considered, comments must be received within the stated 30-day timeframe. We anticipate that most comments will be addressed by April 1 st ; however, a longer timeframe may be necessary to address complex comments or those that require coordination with external parties. If no comments are received, in lieu of a comment response, we will publish a note below the applicable Code List year stating so. 

2024 Annual Update to the Code List

Below you will find the Calendar Year (CY) 2024 Code List published November 29, 2023 and a description of the revisions for CY 2024, our response to comments on that Code List, and the updated CY 2024 Code List, which is effective January 1, 2024 unless otherwise indicated on the Code List.

• UPDATED list of codes effective January 1, 2024, published March 1, 2024 (all codes effective January 1, 2024 unless otherwise indicated on the Code List) (ZIP)
• List of codes effective January 1, 2024, published November 29, 2023 (ZIP)
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2024 (PDF)

We received one comment related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2024. Our response to this comment is below. We also received one comment related to Medicare coverage for platelet-rich plasma treatments. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

Comment : One commenter noted that, although most Hepatitis B vaccine codes are identified on the Code List as CPT/HCPCS codes to which the exception for preventive screening tests and vaccines at § 411.355(h) applies, the Hepatitis B vaccine associated with CPT code 90739 was not listed. The commenter requested that CPT code 90739 be added to the list of vaccine codes to which the exception for preventive screening tests and vaccines at §411.355(h) applies, effective retroactively to January 1, 2024.

Response : We agree with the commenter that the exception for preventive screening tests and vaccines at § 411.355(h) should apply to CPT code 90739 and are revising the Code List accordingly. The applicability of the exception for preventive screening tests and vaccines to CPT code 90739 is prospective only and effective on the date indicated on the UPDATED list of codes. 

In considering this comment, we also identified two CPT codes (90653 and 90658, both flu vaccines) that were inadvertently left off of the list of codes to which the exception for preventive screening tests and vaccines at § 411.355(h) should apply. Accordingly, we are adding these CPT codes to the list of codes to which the exception at § 411.355(h) applies, effective on the date indicated on the UPDATED list of codes.

2023 Annual Update to the Code List

Below you will find the Code List that is effective January 1, 2023 and a description of the revisions effective for Calendar Year 2023. 

• List of codes effective January 1, 2023, published December 1, 2022
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2023, published December 1, 2022 (PDF)

The comment period ended December 30, 2022. We did not receive any comments related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2023. We received one (1) comment related to the supervision level required for specific services. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

DHS Categories

The DHS categories defined by the Code List are:

• clinical laboratory services;
• physical therapy services, occupational therapy services, outpatient speech-language pathology services;
• radiology and certain other imaging services; and
• radiation therapy services and supplies.

The Code List also identifies those items and services that may qualify for either of the following two exceptions to the physician self-referral prohibitions: 

• EPO and other dialysis-related drugs (42 CFR § 411.355(g)).
• Preventive screening tests and vaccines (42 CFR § 411.355(h)).

NOTE: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:

• durable medical equipment and supplies;
• parenteral and enteral nutrients, equipment and supplies;
• prosthetics, orthotics, and prosthetic devices and supplies;
• home health services;
• outpatient prescription drugs; and
• inpatient and outpatient hospital services.

Related Links

• List of codes effective January 1, 2022, published November 19, 2021
• List of codes effective January 1, 2021, issued December 1, 2020
• List of codes effective January 1, 2020, published December 2, 2019
• List of codes effective January 1, 2019, published November 23, 2018
• List of codes effective January 1, 2018, published November 3, 2017 [ZIP, 59KB]
• List of codes effective January 1, 2017, published November 16, 2016 [ZIP, 54KB]
• List of codes effective January 1, 2016, published October 30, 2015 [ZIP, 58KB]
• List of codes effective January 1, 2015, published November 13, 2014 (79 FR 67972) [ZIP, 54KB]
• List of codes effective January 1, 2014, published December 10, 2013 (78 FR 74791) [ZIP, 54KB]
• List of codes effective January 1, 2013, published November 16, 2012 (77 FR 69334) [ZIP, 54KB]

(CPT) Certified Phlebotomy Technician II - 129393

Job description, #129393 (cpt) certified phlebotomy technician ii.

Please note that this position is a part-time appointment

UCSD Layoff from Career Appointment : Apply by 4/24/24 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.

Special Selection Applicants : Apply by 5/3/24. Eligible Special Selection clients should contact their Disability Counselor for assistance.

DESCRIPTION

Performs specimen processing, accessioning, Phlebotomy, heel and finger sticks, customer service, clerical duties, effective communication with laboratory customers, problem resolution, record keeping, supply inventory and maintenance, as well as cleaning and maintaining a safe work environment). Additional duties Include operation of instruments, preventative maintenance as appropriate to each section/dept. assigned. Performs all duties in a manner consistent with current laboratory safety standards. Maintains a current Phlebotomy Certification issued by the state of California Laboratory Field Services.

MINIMUM QUALIFICATIONS

Must be a certified Phlebotomist and hold a valid California Phlebotomy license (CPT).

Previous one to two (1 - 2) years directly related lab experience, preferably in a large, complex healthcare system.

Demonstrated knowledge of Scientific Terminology.

Thorough knowledge of laboratory regulations, laws, and ethical requirements.

Knowledge of Hospital Isolation, Infection Control protocols, patient comfort/safety.

Possess the knowledge, skills, and abilities to perform the duties of the position; demonstrated skills in basic collection and specimen preparation, storage and disposal of specimen.

SPECIAL CONDITIONS

• Employment is subject to a criminal background check and pre-employment physical.
• Must be able to work various hours, days, shifts, on-call and various locations based on the 24-hour Medical Center's business needs.
• Must work variable shifts, weekend rotations, holidays, and swing shifts.
• May be required to travel to other UCSD sites.

Pay Transparency Act

Annual Full Pay Range: $55,624 - $69,134 (will be prorated if the appointment percentage is less than 100%)

Hourly Equivalent: $26.64 - $33.11

Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).

If employed by the University of California, you will be required to comply with our Policy on Vaccination Programs, which may be amended or revised from time to time. Federal, state, or local public health directives may impose additional requirements. If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community .

UC San Diego is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

For the University of California’s Affirmative Action Policy please visit: https://policy.ucop.edu/doc/4010393/PPSM-20 For the University of California’s Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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Posted : 4/19/2024

Job Reference # : 129393

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Interested in working at UC San Diego and UC San Diego Health but can't find a position that's right for you? Submit your resume to our Talent Community to be considered for future opportunities that may align with your expertise. Please note, by joining our Talent Community, you are not applying for a position with UC San Diego Campus and Health. Rather, this is an additional way for our Talent Acquisition team to find candidates with specific credentials, if an opportunity arises. You are still encouraged to regularly check back on our career site or sign up for Job Alerts to apply for openings that are a match for your background.

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Coding Webinars: Arrhythmias and Rheumatoid Arthritis

April 19, 2024

Join our Coding Compliance team for the following webinars on coding and guidelines. They are free to providers and coding professionals. 

The webinars include information on ICD-10-CM documentation and guidelines, sample coding case studies and tips on closing gaps in care for members. The webinars don’t offer continuing education credits. We will present each webinar three times.

Coding for Arrhythmia, including Atrial Fibrillation, Atrial Flutter and Supraventricular Tachycardia  

• May 17, 2024, from noon to 12:30 p.m. Register here.
• June 21, 2024, from noon to 12:30 p.m. Register here.

Coding for Rheumatoid Arthritis and Inflammatory Connective Tissue Disease

• April 26, 2024, from noon to 12:30 p.m. Register here.
• May 31, 2024, from noon to 12:30 p.m. Register here.
• June 28, 2024, from noon to 12:30 p.m. Register here.

Visit our Provider website for more training opportunities.

The material presented in the webinars is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation, coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such resources or organizations. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.