Q: Can you clarify when an evaluation and management (E/M) code can be billed with a physical on the same day?
A: This is always a difficult coding scenario to unravel, but there are a couple of things to keep in mind. Current procedural terminology guidelines for preventive medicine state: “If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem oriented E/M service, then the appropriate E/M service should also be reported.”
The guidelines continue: “An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”
So what does this mean?
Modifier 25 guidance must be followed, as the modifier would need to be appended to the E/M code in this scenario. Medicare and other payers don’t expect that a patient, especially an older patient, wouldn’t have chronic conditions. However, if those conditions are stable and don’t need significant work to address, they would be bundled into the work for the preventive medicine code (99381-99397). Refilling medications and ordering labs for stable chronic conditions are included in the preventive visit. Per the guidelines, this isn’t considered significant additional work.