When a patient is seen for a physical or preventive/wellness visit, and also has acute complaints or chronic problems that require additional evaluation, some physicians encounter challenges when coding and billing for both services. There is confusion about whether it is permissible to bill for acute or chronic care, as well as the preventive service, in the same visit. Sometimes physicians are advised that they cannot bill for both services. Other times they are told they can bill for both but will only receive payment for one, and sometimes there is patient push back when they receive a billing statement with charges they were not anticipating.
Physicians should not bill for both preventive/wellness and evaluation and management (E/M) services when they are performed during the same visit.
When a patient is seen for a physical or preventive/wellness visit, and also has acute complaints or chronic problems that require additional evaluation, some physicians encounter challenges when coding and billing for both services. There is confusion about whether it is permissible to bill for acute or chronic care, as well as the preventive service, in the same visit. Sometimes physicians are advised that they cannot bill for both services, other times they are told they can bill for both but only one will be paid, and sometimes there is patient pushback when they receive a billing statement with charges they were not anticipating.
Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment. The significance of the problem addressed and the amount of time and medical decision making required help determine how the services are most appropriately billed. It is important to accurately and completely document all medically appropriate and necessary care performed during a patient encounter and to bill for what is documented. Many physicians, usually motivated by a desire to avoid audits, tend to under-code for the work they have performed, resulting in significant amounts of uncompensated care.
The Current Procedural Terminology (CPT®) guidelines provide clarification. If an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive/wellness visit, and the problem or abnormal finding is significant enough to require additional work to perform the key components of a problem-focused evaluation and management service, then the appropriate office/outpatient E/M code should also be billed. Modifier-25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported. An additional E/M code should not be billed if the addressed problem/abnormality is insignificant or trivial and does not require additional work and the performance of the key components of a problem-focused E/M service.1
When billing Medicare, CMS requires that additional qualifying E/M services be billed separately from the preventive service. The CMS website states “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code with Modifier-25. That portion of the visit must be medically necessary and reasonable to treat the patient's illness or injury, or to improve the functioning of a malformed body part.”2 Commercial payers, depending on the patient's specific policy, may or may not cover the additional problem-focused E/M service billed at the same visit as the preventative service. Whether the services are being billed to a commercial payer or Medicare, using Modifier-25 properly will help ensure the charges eligible for payment are processed correctly.
Billing additional codes may affect the patient's out-of-pocket financial responsibility for a visit. Physicians may choose to discuss this possibility with their patients at the time of service to help avoid confusion and frustration related to unexpected charges. Practice billing staff should also be familiar with the payers and their policies to minimize the risk of unanticipated charges.