When an E/M code can be billed with a physical on the same day

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.”

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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. 

Next: E/M case study

Case Study

A 34-year-old established patient comes in for her yearly physical. During the visit, the physician learns that the patient has gained an abnormal amount of weight since her last appointment.  The physician discusses healthy eating habits and exercise with the patient and, with the patient being overweight with a BMI of 26, decides to watch the patient’s weight. 

In this situation, the preventive visit includes reviewing the patient’s weight, anticipatory guidance and risk-factor reduction, so all of the work performed would be included in the preventive medicine code. An additional E/M code would not be supported, so the following would be billed:

 99395  (Periodic comprehensive preventive medicine reevaluation 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, established patient; 18-39 years)

• Z00.00 (Encounter for general adult medical exam without abnormal findings)

• R63.5 (Abnormal weight gain)

• E66.3 (Overweight)

• Z68.26 (Body mass index (BMI) 26.0-26.9, adult)

However, if a patient has an acute problem or an exacerbation of a chronic condition that does require additional work that the physician/provider wouldn’t normally perform in the course of a physical, an E/M code can be billed in addition to a preventive visit.  

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In order to code under this scenario, all of the elements performed as part of the physical are counted toward the preventive medicine code. Only those elements that constitute the significant additional work would count toward the E/M code level. 

The key is to know when the additional workup is significant enough to warrant a separate code. You must have an illness that requires its own, separate evaluation, with a history or physical exam and medical decision-making all related to that separate problem.

An established E/M code should be billed with a preventive code.