Preventive Medicine Services Coding Guidelines

Basics of Preventive Care

Preventive care helps detect or prevent serious diseases and medical problems before they can become major. Annual check-ups, immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This may also be called routine care. While coding, you need to understand the difference between preventive care and diagnostic care. Diagnostic care is related to services in which your provider is looking for something specific, often based on the results of a preventive test or screening. For example, a radiologist may ask for a follow-up mammogram for a patient. This follow-up is to check for something that may have been detected during the preventive or routine mammogram. The follow-up mammogram is diagnostic, and not covered as preventive care. Let’s understand preventive medicine services coding guidelines for the year 2022.

Preventive Medicine Services Coding Guidelines

  • Preventive medicine services include measurements (e.g., length/ height, head circumference, weight, body mass index, blood pressure) and age- and gender-appropriate examination and history (initial or interval).
  • Preventive medicine service codes are not time-based; therefore, time spent during the visit is not relevant in selecting the appropriate preventive medicine service code.
  • If an illness or abnormality is discovered, or a pre-existing problem is addressed, in the process of performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the components of a problem-oriented evaluation and management (E/M) service (i.e., using medical decision making or time spent), the appropriate office or other outpatient service code (99202–99215) should be reported in addition to the preventive medicine service code. Append modifier 25 to the office or other outpatient service codes (e.g., 99392 and 99213 25).
  • An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service should not be separately reported.
  • The comprehensive nature of the preventive medicine service codes reflects an age- and gender-appropriate history and physical examination and is not synonymous with the comprehensive examination required for some other E/M codes (e.g., 99204, 99205, 99215).
  • Immunization products and administration and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (e.g., vision, developmental, hearing) identified with a specific CPT code, are reported and paid for separately from the preventive medicine service code.

Preventive Medicine Services: New Patients

Initial comprehensive preventive medicine E/M of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures. A new patient is defined as one who has not received any professional face-to-face services rendered by physicians and other qualified health care professionals (QHPs) who may report E/M services and reported by a specific CPT code(s) from a physician/other QHP, or another physician/other QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

Preventive Medicine Services: Established Patients

Periodic comprehensive preventive medicine re-evaluation and management of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures.

Preventive Medicine Services: With and Without Abnormal Findings

The use of an ICD-10-CM code for with abnormal findings (e.g., Z00.121) does not mean that an additional E/M service must or can be used. Abnormal findings can be trivial or incidental issues that do not require additional work, but the condition is still documented or listed as contributory. Examples of abnormal findings include abnormal screening results, new acute problems, or unstable or worsening chronic conditions. A stable chronic condition (whether addressed or not) would not warrant the use of an abnormal findings code. You can link an abnormal findings ICD-10-CM code to a screening if the screen is normal; the abnormality will be identified with the appropriate ICD-10-CM code so the payer will be aware.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred ‘Coding and valuation page of American Academy of Pediatrics (AAP)’ to discuss preventive medicine services coding guidelines.

Still, you can refer to payer-specific coding guidelines and reimbursement policies to receive accurate insurance reimbursements. For any assistance in medical billing and coding for your practice, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.