Annual Preventive and Wellness Visit Service

Preventive Service Codes

The annual preventive exam is a periodic, comprehensive preventive medicine evaluation (or reevaluation) and management of the patient.

The CPT Code selection is based on whether the patient is receiving an initial visit -"New Patient" or a periodic - "Established Patient" preventive service, as well as the patient’s age.

• Initial Visits - 99381, 99382, 99383, 99384, 99385, 99386, 99387
• Subsequent Visits - 99391, 99392, 99393, 99394, 99395, 99396, 99397

The Medicare insurance would be covered by "G" codes instead of the above codes. The details below,

• Welcome to Medicare - G0402 (Within the one year from the patient enrolled in Medicare)
• Initial Annual Wellness Visit - G0438 (After the 1st year of enrollment)
• Subsequent Annual Wellness Visit - G0439

Initial Visits

Initial comprehensive preventive medicine evaluation and management of an individual including an" age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures", New patient,

• 99381 - Infant (age younger than 1 year)
• 99382 - Early childhood (age 1 through 4 years)
• 99383 - Late childhood (age 5 through 11 years)
• 99384 - Adolescent (age 12 through 17 years)
• 99385 - 18-39 years
• 99386 - 40-64 years
• 99387 - 65 years and older

Subsequent Visits

Periodic comprehensive preventive medicine reevaluation and management of an individual including an "age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures," established patient,

• 99391 - Infant (age younger than 1 year)
• 99392 - Early childhood (age 1 through 4 years)
• 99393 - Late childhood (age 5 through 11 years)
• 99394 - Adolescent (age 12 through 17 years)
• 99395 - 18-39 years
• 99396 - 40-64 years
• 99397 - 65 years and older

Included Services

Checking the status of "chronic conditions" and "refilling ongoing prescriptions" is expected during an annual preventive exam and does not warrant the billing of a separate problem-oriented E/M service.

If a chronic condition is not being well controlled, however, and decisions are being made as to how to treat the patient to improve control (changing the dosage of medications, changing to a new medication, etc.), this may substantiate a separate problem-oriented E/M service.

Documentation

• Medical and family history
• List of current medical providers
• Height, weight, BMI, BP, and other appropriate routine measurements
• Detection of cognitive impairment
• Review risk factors – Review of functional ability
• Establish a written screening schedule for the next 5-10 years
• Establish a list of risk factors
• Provide advice and referrals to health education and preventative counseling services

Tips - CPT G0402 & G0438 covered once in a lifetime for the patient.

See E/M 2021E&M guidelines

Level of History - Evaluation and Management

Definition and Details of  History

Level of  History

There are four levels of History found in E/M,

• Problem Focused History
• Expanded Problem Focused History
• Detailed History
• Comprehensive History  

The problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), 

The Expanded Problem Focused History requires documentation of the chief complaint (CC) and a brief history of present illness (HPI) and Problem Pertinent review of system

The Detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).

The Comprehensive history requires the documentation of a CC, an extended HPI, plus an Complete review of systems (ROS), and Complete past, family, and/or social history (PFSH).

Chief Complaint (CC) 

A Chief Complaint or reason visit/ reason for appointment is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. 

The CC is usually stated in the patient’s own words. For example, patient complains of chest pain and radiating to shoulder, and  denied shortness of breath. The medical record should clearly reflect the CC.

History of Present Illness (HPI) 

The HPI is a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present

The HPI elements are,

• Location (example: left leg)
• Quality (example: aching, burning, radiating pain)
• Severity (example: 10 on a scale of 1 to 10)
• Duration (example: started 3 days ago)
• Timing (example: constant or comes and goes)
• Context (example: lifted large object at work)
• Modifying factors (example: better when heat is applied)
• Associated signs and symptoms (example: numbness in toes) 

There are two types of HPI,

A Brief HPI includes documentation of one to three HPI elements. 

An Extended HPI, 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities. In 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions

Review of Systems (ROS)

ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. 

These systems are recognized for ROS purposes,

• Constitutional Symptoms (for example, fever, weight loss)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

The three types of ROS are problem pertinent, extended, and complete.

A Problem Pertinent ROS inquires about the system directly related to the problem identified in the HPI

An Extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

A Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. 

• The Provider must individually document those systems with positive or pertinent negative responses. 

• For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

Past, Family, and/or Social History (PFSH)

PFSH consists of a review of three areas,

1. Past history includes experiences with illnesses, operations, injuries, and treatments

2. Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk

3. Social history includes an age-appropriate review of past and current activities

The two types of PFSH are pertinent and complete

A Pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. 

The pertinent PFSH must document at least one item from any of the three history areas.

A Complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. 

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. 

For Details of MDM 

Office-Based Opioid Use Disorder (OUD) Treatment Billing

The CMS included new coding and payment for a monthly bundle of services for the treatment of (Opioid Use Disorder) OUD that includes,

• Overall management
• Care coordination
• Individual and group psychotherapy
• Substance use counseling
• Add-on code for additional counseling

The provider to bill for a group of services in the office setting similar to the services covered under the Opioid Treatment Program benefit for clinics.  

Clinicians providing these bundled services to Medicare patients should use these codes,

G2086 - In the first calendar month,

• Developed the treatment plan
• Coordinated care
• Provided at least 70 minutes of individual therapy and group therapy and counseling

G2087 - In a subsequent calendar month,

• Coordinated care
• Provided at least 60 minutes of individual therapy and group therapy and counseling

G2088 -  In a subsequent calendar month,

• Coordinated care
• Provided more than 120 minutes of therapy and counseling
• Note: Bill each additional 30 minutes separately and include the code for the primary procedure
• CPT G2088 add-on code to be reported with CPT G2087

Tips

• G2086 to report the development of a  treatment plan, care coordination, and counseling of at least 70 minutes in the first calendar month

• G2087 to report treatment, care coordination, and counseling of at least 60 minutes after the first month, 

• G2088 for each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure).

Clinical Example for Critical Care

Clinical Examples - Critical care services

An 85-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent.

A 66-year-old female patient is 4 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support.

A 72-year-old male admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission.

A 58-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy

Clinical Examples - Non Covered Critical care services

The Patients admitted to a critical care unit because no other hospital beds were available.

The Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose).

The Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.

Example: 

A dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that is being managed by an intensive visit. The dermatologist should not report service for critical care.

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New Lab Codes Effective July 1, 2021

The New HCPCS Lab Codes are released which is Effective from July 1, 2021. These new codes are contractor-priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process. 

The MACs will only price PLA codes for laboratories within their jurisdiction. and Type of Service (TOS) for all the codes should be "5".

0248U - Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug.

0249U - Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report.

0250U - Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden.

0251U - Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma.

0252U - Fetal aneuploidy short tandem–repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy.

0253U - Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by nextgeneration sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive).

0254U - Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested.

G0327 - Colorectal cancer screening; blood-based biomarker.

Critical Care Guidelines - CPT 99291 and 99292

Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. 

Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions. 

Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services.

Examples of vital organ system failure include, but are not limited to,

• Central nervous system failure, 
• Circulatory failure, 
• Shock, 
• Renal, hepatic, metabolic, and/or respiratory failure. 

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of attention mentioned above.

Key Points

The Critical Care Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Critical care and other E/M services may be reported to the same patient on the same date by the same individual.

The critical care code is applicable for a critical care service provided for the first 30 – 74 minutes. Any Critical Care service provided for less than 30 minutes should be billed with the appropriate level of E/M code.

Usually, a Critical Care service is provided to a patient in a "Critical Care Area" such as,

• Coronary Care Unit (CCU), 
• Intensive Care Unit (ICU), 
• Respiratory Care Unit, or 
• Emergency Room.

Included Services

The mentioned below list of services are included when performed during the "Critical Care service"

• Interpretation of cardiac output measurements - 93561, 93562
• Chest X rays -71045, 71046
• Pulse oximetry - 94760, 94761, 94762[blood gases, and collection and interpretation of physiologic data] (eg, ECGs, blood pressures, hematologic data);
• Gastric intubation - 43752, 43753
• Temporary transcutaneous pacing - 92953 
• Ventilatory management - 94002-94004, 94660, 94662 
• Vascular access procedures - 36000, 36410, 36415, 36591, 36600

Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.

Tips

Inpatient critical care services provided to neonates (28 days of age or younger) are reported with the neonatal critical care codes 99468 and 99469. 

Inpatient critical care services provided to infants 29 days through 71 months of age are reported with pediatric critical care codes 99471-99476

To report critical care services provided in the outpatient setting (eg, emergency department or office), for neonates and pediatric patients up through 71 months of age, see the critical care codes 99291, 99292

Click here to check TCM

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Transitional Care Management (TCM) Guidelines

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM).

These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either "Moderate Complexity or High Complexity".

To qualify for Transitional Care Management (TCM) services, the patient must be discharged from one of the following facility settings,

•  Acute Care Hospital
•  Psychiatric Hospital
•  Rehabilitation Facility
•  Long-term Care Hospital
•  Skilled Nursing Facility
•  Partial hospitalization
•  Hospital outpatient observation
•  Partial hospitalization at a community mental health center

Additionally, the patient must be returned to one of the following community settings,

•  Home
•  Domiciliary (e.g., group home or boarding house)
•  Nursing Facility (e.g., boarding home or adult care home)
•  Assisted Living Facility

Guidelines

• TCM is included in one face-to-face visit within the specified time-frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional.

• Only one individual may report these services and only once per patient within 30 days of discharge.

• Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

• The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.

Non-Face To Face Service

Non-face-to-face services provided by the physician or other qualified health care provider may include,

• Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents).

• Reviewing the need for or follow-up on pending diagnostic tests and treatments.

• Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.

• Education of patient, family, guardian, and/or caregiver.

• Establishment or reestablishment of referrals and arranging for needed community resources.

• Assistance in scheduling any required follow-up with community providers and services.

The first face-to-face visit is part of the TCM service and not reported separately. 

Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. 

Interactive Communication

For TCM requires interactive contact with the patient or caregiver, as appropriate, within two business days of discharge and the communication typically involves following,

1. In-person visits: Face-to-face visits with the healthcare provider allow for a more comprehensive assessment of the patient's health status and the ability to address any issues that may arise. 
2. Telephone calls: Providers may call patients or caregivers to discuss the patient's condition, medications, follow-up appointments, and any other necessary information.
3. Secure messaging: Some healthcare providers use secure messaging platforms to communicate with patients, allowing for quick and convenient exchange of information.
4. Video visits: Telehealth visits via video conferencing can be used to conduct follow-up visits, assess the patient's progress, and address any concerns.

CPT Codes

• CPT 99496 -The face-to-face visit must occur within 7 calendar days of the date discharge and MDM must be of "High complexity". 

• CPT 99495 -  The face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be "Moderate complexity".

Documentation

For Transitional Care Management (TCM) services, the following elements must be documented in the patient's record:

1. Date of discharge from acute care
2. Date of provider contact with the patient (two days post-discharge)
3. Date of face-to-face visit with the provider (either 7 days or 14 days post-discharge)
4. Complexity of the Medical Decision Making (MDM), documented as either moderate or high

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