When a “Problem” is Discovered During Preventive Medicine Encounter

This is the first article of a three-part series addressing coding challenges associated with preventive medicine services.

Part 1 – When a “Problem” is Discovered During Preventive Medicine Encounter

Part 2 – ICD-10-CM Coding in Preventive Medicine

Part 3 – Pediatric Preventive Medicine – Vaccine Administration

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We know the extent and focus of a preventive service is dependent upon the patient’s age. CPT® guidance tells us an “age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures” are all inherent to the preventive service.

With so many elements bundled into the preventive E/M code, how do we determine when we’re providing additional services outside the realm of the preventive visit, particularly when we discover a problem during the encounter?

To clarify, CPT® states that “an insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E/M 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.”

While CPT® does not define what would be considered “insignificant or trivial,” we can ask ourselves a few simple questions to assist in determining if the problem(s) or abnormal finding(s) would be significant enough to warrant the additional work required to report a separate, problem-oriented E/M.

  • Would the problem(s) on its/their own have required a separate encounter?
  • Does it require medical decision making (MDM) in assessing and treating the problem(s)?
  • Did the problem(s) require considerable time to evaluate, discuss, answer questions, and manage beyond the normal amount of time for a preventive medicine encounter for a similar-aged patient? Keeping in mind the need to exclude the time spent in preventive medicine activities and other separately reported services.
  • Is there additional documentation to support the MDM or total time addressing the problem(s)?

If you can answer yes to any of these questions, it may be appropriate to report an office or other outpatient E/M code (99202-99215) in addition to the preventive medicine service.

Some problems that may support reporting a separate E/M include:

  • A new condition that requires additional work
    • Positive depression screener warranting further evaluation and/or treatment
    • Upper respiratory infection requiring OTC medication
    • History of and presenting with elevated blood pressure resulting in a diagnosis of hypertension with medication being initiated
  • Exacerbation of a chronic condition
    • Diabetes mellitus with worsening A1C requiring changes in medication
    • Asthma flares requiring maintenance inhaler in addition to rescue inhaler
    • ADHD worsening requiring changes in medication

The following are likely to be considered incidental to the preventive medicine service:

  • Medication refills with no exacerbation
  • Minor complaint or finding with very minimal work, such as diaper rash or seasonal allergies that likely would not have resulted in a separate appointment
  • Chronic condition that is stable and not required to be addressed such as eczema or ADHD

The provider’s discretion and documentation will determine when it may be appropriate to report a separate, problem-oriented E/M service as every encounter and circumstance will be different.

Let The Rybar Group help you determine if you are capturing separate, problem-oriented E/M services in a compliant manner. Our experienced and knowledgeable audit team performs numerous audits every year in primary care and pediatrics, enabling practices to identify missed revenue opportunities while also educating practitioners on improving documentation on all services provided. Contact us today to inquire about our chart auditing and provider education services.

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