Health Assessments, Office Visits and Modifier 25, Oh My!

Many providers find coding Preventive Medicine (Health Assessments) and Office Visits very confusing. In fact, many feel that it is not worth it. It seems simple enough, an established 34-year-old male patient comes in for their annual health assessment and also have other conditions like HTN, Diabetes Mellitus and Hyperthyroidism that were addressed. Why shouldn't I be able to use a Preventive Medicine code (99395) with at least a low-level established patient visit (99213) and modifier 25?

Well your partially right. See, a Health Assessment is.... well exactly that. It is an assessment of your patients overall health. The extent and focus of the services will largely depend on the age of the patient. When a provider conducts a health assessment it is expected that the provider will chart a comprehensive age and gender appropriate history /exam. At this time I would like to explain the term "comprehensive". As you may be aware, Office visits have Comprehensive history and exams too. However, Comprehensive in a Health Assessment (99381-99397) is not synonymous with comprehensive exam in an office visit (99201-99215). Meaning, the Nature of the presenting problem dictates the elements in your history, exam and medical decision-making for office visits. In other words, if a patient presents for a splinter on a finger, a comprehensive history and exam should not have to be attained to gather the information, and the medical decision-making should only show the necessary treatment for removing a splinter (Always remember medical necessity). Other important facts about health assessment are anticipatory guidance, risk factor reduction interventions or counseling, and management of insignificant problems.

So, what should you do when you have a patient with an acute condition (chest pain) and/or chronic condition (HTN) presenting for an annual Health Assessment?

You should take a comprehensive history, comprehensive exam and order proper laboratory/diagnostic procedure. Now lets take a look at the acute and/or chronic conditions. Providers should ask themselves if the condition is requiring work up that is over and beyond their usual. Remember, documentation guidelines are not the same for health assessment. In other words, Health Assessments does not rely on a chief complaint or a history of presenting illness. Also, a health assessment is not problem oriented. Health Assessments rely on a comprehensive ROS (Review of Systems), a comprehensive PFSH and a comprehensive assessment of risk factors. Since you already documented a comprehensive history and exam, this would be considered overlapping. Therefore, the E/M reported for the problem visit (99201-99215) should be based on additional work performed by the provider in determining the best course of action in treating this problem.

Ask yourself, can this condition stand on its own? Is this condition significant enough to have its own encounter?

When using an office visit code (99201-99215) with a health assessment (99381-99397), a modifier 25 should be used to show the separately identifiable service that was performed within the annual exam.

Modifier point: Modifier 25 is used to show a significant, separately identifiable evaluation and management, service by the same physician on the same day of the procedure or other service. This modifier can only be appended with an E/M code.

Preventive Medicine Example:

34-year-old male comes in for routine annual visit. Patient is also noted to have HTN. HTN is stable w/ diet and medication. Patient has no complaints. A comprehensive history and exam is taken. Provider orders labs and tells patient to continue with current medication.

S: Patient here for annual follow-up. Patient has HTN. No complaints.

No f/c, chest pain, dyspnea, blurry vision, sore throat, n/v, allergies, lymph abnormalities, thyroid problems, urinary incontinence,

Medical hx: HTN

Family hx: father has DM

Social: non smoker, social drinker, married

O: 130/70, 96.7

HEENT: anicteric sclera, ENT: normal

Cardio: normal RRR

Lungs: Clear to Auscultation

Ext: good ROM, no abrasion, no edema, skin tight

Neck: no lad

Neuro: A&O x3,

GI: soft nontender, normal BS

Gu: Normal

Anticipatory guidance discussed about exercise and medication. Patient indicates understanding

Assessment: health checkup,HTN

Plan: Continue meds as ordered.

Dx(s): V70.0, 401.9

CPT: 99395

Preventive Medicine with office visit example:

52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. No f/c, dyspnea on exertion, n/v. Remember, you are going to document additional history to support the exacerbated condition. Your exam is going to still comprehensive for the health assessment with extra documentation of the affected area(s) (Cardiovascular and Respiratory). An EKG and chest X-ray is ordered and reviewed. Your final diagnosis is acute bronchitis and chest pain.

Assessment: health checkup, Acute Bronchitis, Chest pain

Plan: Medication for Acute Bronchitis is prescribed.

Dx(s): V70.0, 466.0

CPT: 99397 (Health Assessment)

99213(Problem visit) -25 (Significant, separately identifiable service by same provider on same day)

93000 (EKG)

71020 (Chest xray, PA and lateral)

Please note, the above cases are examples only. As with all documentation, providers should always report the correct level of service by the documented history, exam and medical decision making. To find more examples of using preventive medicine codes with and without office visits, go to your respective medical societies; AAFP, ACOG, etc... They are ALWAYS a great resource for information!

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