Let’s say a patient comes in for a preventive medicine service and you end up also treating an acute or chronic problem. How do you quickly determine if you should add a second service and bill for a separate problem-oriented visit? In other words, when should you bill an office/outpatient service (CPT codes 99212-99215) on the same day as a preventive medicine service (CPT codes 99381-99397) or a Medicare wellness visit (HCPCS codes G0402, G0438, or G0439)?
Here’s some quick guidance from CPT: If a new or existing problem is addressed at the time of a preventive service and is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service, you should bill for both services with modifier 25 attached to the latter. Likewise, the Center for Medicare & Medicaid Service’s (CMS) guide to wellness visits states that when you furnish a significant, separately identifiable, medically necessary E/M service with a wellness visit, add the E/M service with modifier 25. “That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member,” says CMS.
In your documentation, you should describe in the history of the present illness all of the patient’s acute or chronic conditions and should detail in the assessment and plan how you managed them, making sure to show your extra cognitive work. This could include ordering or reviewing diagnostic tests, renewing prescriptions, making referrals, or implementing other changes to treatment. Note that neither CPT nor CMS requires a change in treatment to support billing for a second separate service.
Family physicians are sometimes reluctant to add this second service because they know the patient will be charged a copay or, depending on the deductible, the full fee for the problem-oriented visit. However, performing two services but charging for only one isn’t reasonable for practice revenue and doesn’t follow CPT rules.
— Betsy Nicoletti, a Massachusetts-based coding and billing consultant
Posted on Apr 19, 2018 by David Twiddy
FAQs
Here's some quick guidance from CPT: If a new or existing problem is addressed at the time of a preventive service and is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service, you should bill for both services with modifier 25 attached ...
Can you bill 99395 and Q0091 together? ›
If using CPT® preventive medicine services, and also performing a screening pap smear report a code in 99381-99397 series and Q0091. If using E/M codes for a symptom or condition and practitioner also obtains a pap smear report only the E/M service. Do not report Q0091 because it is for obtaining a screening test.
Can you bill 99396 and 99213 together? ›
In this case, the clinician would report the appropriate preventive service visit (such as 99396) on one line of the claim form, followed by the problem-oriented E/M visit (such as 99213) with modifier 25 appended on the next line.
Can you bill 99397 and G0439 together? ›
Correct you can only bill one or the other (medicare annual wellness or a preventative examination). However if documentation supports it you can split bill the visit with a 99212 or 99213 with a modifier 25 attached.
What is required for billing preventive services & problem-oriented encounters on the same day? ›
When a preventive medicine visit and a problem-oriented Evaluation and Management (E/M) visit are reported on the same day for the same patient by the same provider, the reimbursem*nt for the problem-oriented visit will be reduced. 2. Modifier 25 needs to be added to the problem-oriented E/M visit procedure code.
Can G0101 and Q0091 be billed together? ›
I do Ob/gyn coding and from my notes it says Q0091 is billed for doing the screening pap smear and G0101 is billed for the pelvic exam and breast check. So if both were done, you use both Q0091 and G0101 for medicare patients and you need to use diagnosis V76. 2.
How to bill 99395 and 99213 together? ›
can be used 99213 with 99395 at the same visit? Absolutely! You would use the modifier -25 on the 99213. Look at the Preventive Medicine section in CPT® and this is outlined in the narrative explanation prior to the actual listing of codes.
Can an office visit and preventive visit be billed together? ›
CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care.
What is the 57 modifier used for? ›
CPT modifier 57 may be used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
Can I use modifier 25 on a preventive visit? ›
Modifier 25 should be appended to the office or other outpatient visit code to indicate that a significant, separately identifiable E/M service was provided on the same date as the preventive medicine E/M service, and the appropriate preventive medicine E/M service is additionally reported without a modifier.
Yes, in some cases, you can bill two E&M (Evaluation and Management) codes for the same patient on the same day, but it depends on payer rules and documentation requirements.
Can 99386 and 99204 be billed together? ›
Generally, 99204 (office visit) and 99386 (preventive medicine service for a new patient of a certain age) might not be billed together for the same patient on the same day as they cover different aspects of care.
Can you bill a telehealth and office visit on the same day? ›
E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient.
What modifier to use for two visits in one day? ›
Modifier 25 is used to signify that when a separate identifiable evaluation-and-management (E/M) service was performed, which can refer to two evaluation-and-management (E/M) services, or a procedure plus an E/M service.
How to code a preventive visit? ›
Preventive visit codes 99381-99397 include “counseling/anticipatory guidance/risk factor reduction interventions,” according to CPT. However, when such counseling is provided as part of a separate problem-oriented encounter, it may be billed using preventive medicine codes 99401-99409.
What is a 25 modifier used for in medical billing? ›
Modifier 25 – this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.
What modifier can be used with Q0091? ›
Physicians billing for reconveyances shall use Q0091 with modifier -76 in order to receive payment for reconveyances. A new diagnosis V72. 31 shall be added to the edits in CWF for low risk beneficiaries.
Does CPT Q0091 need a modifier? ›
If a physician performs a Pap Smear (obtaining the specimen, preparing the slide, and conveyance - Q0091) and an unrelated, separately identifiable E/M on the same day both services may be billed. The appropriate medical E/M office visit code (99202-99215) may be reported with modifier 25 in addition to Q0091.
Can you bill for two CPT codes at the same time? ›
There is a myth that exists that you can't bill 2 CPT codes during the same 15-minute time period. Well, that myth is only partially true. It is possible to bill 2 CPT codes during the same 15-minute time period.
Can you bill G0439 with Q0091? ›
An annual or subsequent wellness visit (G0438/G0439) is reported for the examination, plus the breast/pelvic exam (G0101) and the pap smear (Q0091.
