Q&A: Charging for different services on the same visit

Dealing with patient phone calls after hours is no easy task. Protecting yourself from liability in these cases takes good communication skills and thorough documentation.

Can I bill 99397 for a preventive service and 99212–25 for the same office visit, since the primary reason for the visit was for 99397?

Yes, if there is a separately identifiable E/M service unrelated to the preventive service provided during the same patient visit. Documentation for the preventive service may not be used to support the 99212 charge. A separate note should be made to support the level of E/M service charged, including the chief complaint, level of history appropriate to the complaint, exam, medical decision making, and treatment plan. Use of the modifier 25 will depend on the insurer involved. While CPT and Medicare rules allow both services to be billed, not all insurers will recognize two separate services (or even preventive services), so your billing staff may have a challenge getting the claim paid.