Coding Insights: Billing for preventive care and additional services

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.

NEXT: The new code for 3D mammograms

Q:Many of our patients are asking if they can get the 3D mammogram. Is there a code available for this?

A: Effective in 2015 there is a new CPT code for 3D imaging:

• 77063 : Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure.

This is an add-on code, and it must be billed in conjunction with a primary screening mammography code in order to be reimbursed.

In CMS’ MLN Matters® Number MM8874, Medicare instructs that 77063 is an add-on code to G0202 (Screening mammography, producing direct digital image, bilateral, all views), which is for 2D imaging only.

Here are some additional coding tips:

• The same policies that are applicable to other screening mammography codes are applicable to CPT code 77063.

• Since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital mammography.

• Payment for 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12 (and when ICD-10 is effective with ICD-10 code Z12.31).

• Beneficiary coinsurance and deductible does not apply when 77063 is billed.

Since this code is so new, it isn’t clear yet which other insurance carriers are reimbursing for it.

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.