Primary Preventive Medicine Services Codes – A Guide for Medical Billers and Medical Coders
The doctor checks acute/chronic ailments during routine visits. However, another approach promotes proactive health and addresses concerns promptly.
‘Preventive Care Visits’, prevent illnesses & are annual check-ups by a Primary Care Physician. Preventive and evaluation visits are the foundation of internal and family medicine practices. Preventive visits identify health issues early through normal and abnormal findings.
Even if it seems like a little simpler concept on paper, it comes with its little caveats. This article covers preventive care basics and billing for effective reimbursement over time.
Preventive care Coding: What code to use?
To bill preventive services, use codes based on insurance coverage.
1) If the patient has Medicare, use these codes below:
Medicare Annual Wellness Visit (AWV) codes: G0438-G0439 and IPPE Visit
G0438: Annual wellness visit; includes a personalized prevention plan of service, initial visit
G0439: Annual wellness visit, includes a personalized prevention plan of service, subsequent visit
G0402: Welcome to Medicare visit; Initial Preventative Physical Exam (IPPE)
Prolonged Preventive Services that can be billed with G0438 or G0439
G0513: Prolonged preventive service: 30 minutes.
G0514: Additional 30 minutes of prolonged preventive service (list separately).
2) If the patient is following Commercial Payers, Preventive Medicine Services Codes are used instead:
Primary preventive medicine services Codes:
These codes are billed based on the Beneficiary’s age
99381-99387 - New Patient Preventive Medicine Services
99391-99397 - Established Patient Preventive Medicine Services
Frequency - How many times you may bill this code?
New Medicare Part B patients get a one-time benefit in the first 12 months. Annual Medicare visits are after 11 months of the initial visit.
Medicare visits include EKG, vaccines, labs, counseling, and medical management. Preventive visits vary by insurance plan.
Well-baby
Well-child
Wellness Visit for Adults
Well-woman
What these visits might include or can lead to?
- Complete physical exam
- A thorough review of your general health and well-being
- A health risk assessment (HRA) – 96160 or 96161
- Advance care planning - 99497
- Developmental and cognitive impairment screenings - 96110 or 99483
- Managing ADLs – 97750 or 97535 (Limited to PT/OT)
- Counseling on such topics as:
Quitting smoking - 99406
Losing weight and eating healthy - G0447
Treating depression - G0444 or 96127 for PHQ or GAD tests
Reducing alcohol use - G0442
- Blood pressure and cholesterol screening tests
- Bone Mass Measurement and Osteoporosis prevention
- Diabetes control – management of blood glucose – 82947 -82951
- STDs testing including Pelvic exams, pap smears and counseling – G0445 or G0101
- Many cancer screenings, including mammograms - 77063 and colonoscopies including lung- G0296, 71271, Prostate - G0102, G0103 and colorectal cancer screenings - G0104 -G0328
- Immunization review and update
- Flu shots and other vaccines – G0008-G0010
- Routine vaccinations against diseases such as measles, polio, or meningitis
- Counseling, screening, and vaccines to ensure a healthy gestation period
- And the list can go on…
Coverage:
Preventive care is often fully covered by health plans, offering economic & health benefits. The healthcare provider may determine which services are most suited to the patient. However, insurance may require copays if preventive care is not the main reason for the visit.
Who can perform these visits?
Any provider who bills E/M services can bill for these visits on an annual basis. In-network options: primary care, general practitioner, or Family Medicine specialist.
Who is eligible for them?
Preventive visits aim to improve illness prevention and management for all patients. They are available to patients regardless of their present health situation. Preventive visits catch problems early before they worsen.
Some of the commonly used Diagnosis codes related to Preventive Visits are:
- Z00.110 ….. Health examination for newborns under 8 days old
- Z00.111 ….. Health examination for newborns 8 to 28 days old
- Z00.121 ….. Encounter for routine child health examination with abnormal findings
- Z00.129 ….. Encounter for routine child health examination without abnormal findings
- Z00.00 ……. Encounter for general adult medical examination without abnormal findings
- Z00.01 ……. Encounter for general adult medical examination with abnormal findings
What other ancillary services can be billed with AWVs?
Vaccinations administration with AWVs:
Immunization, undoubtedly has been hand-in-hand with these annual visits. Medicare Part B provides coverage for specific vaccination types including:
Seasonal Influenza Virus
Pneumococcal
Hepatitis B
Administration codes for Medicare Covered Vaccinations:
G0008 — Administration of Influenza vaccine
G0009 — Administration of Pneumococcal vaccine
G0010 — Administration of Hepatitis B vaccine
These Administration HCPC codes are followed by Vaccine CPT codes. Administer pneumococcal vaccine with HCPCS G0009 and pair with CPT 90671 for PCV15. However, don’t forget to add NDC and other required information to your claim. Use Modifier 25 with any E/M performed the same day to denote the visit as separately identifiable. Private payers
ICD-10 Codes
For Medicare vaccinations, use Z23 for the ICD-10 diagnosis.
Vaccination: Who is Covered/Frequency:
- All Medicare beneficiaries
- Once per influenza season (Medicare covers additional flu shots if medically necessary)
- First pneumococcal vaccine for Medicare beneficiaries new to Medicare Part B.
- A different, second pneumococcal vaccine one year after the first vaccine was administered
- Medicare beneficiaries with hepatitis B antibodies are ineligible for the pneumococcal vaccine benefit.
- Alcohol Misuse Screening & Counseling HCPCS & CPT Codes.
Alcohol Misuse Screening & Counseling HCPCS & CPT Codes
Screening and Counseling in Primary Care to Reduce Alcohol Misuse.
G0442 — Annual alcohol misuse screening, 5 to 15 minutes
G0443 — Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Frequency
G0442 — Annually - Billed once per year (screening +/-)
G0443 — If they screen positive for misuse, 4 times per year (counseling)
ICD-10 Codes
Diagnosis code Z13.89 can be used for screening for alcohol misuse. Use F10.10 or F10.129 for alcohol abuse when providing counseling.
Medicare Covers Patients with Medicare Part B who:
- Positive screen for alcohol misuse without meeting dependence criteria.
- Are competent and alert during counseling
- Receive counseling from a primary care provider in a primary care setting.
Depression Screening HCPCS & CPT Codes
Also known as Screening for Depression in Adults.
G0444 — Annual depression screening, 5 to 15 minutes
Frequency: Annually
ICD-10 Codes
Diagnosis codes Z13.31 or Z13.89 can be used for screening of depression.
Intensive Behavioral Therapy (IBT) for Obesity HCPCS & CPT Codes
G0447 — Face-to-face behavioral counseling for obesity, 15 minutes
G0473 — Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
Medicare Covers screening for obesity in patients with Medicare Part B who:
- Have a body mass index (BMI) ≥ 30 kilograms (kg) per meter squared
- Are competent and alert during counseling
- Receive counseling from a primary care provider in a primary care setting.
- Obesity reassessment and weight loss determination are required at a 6-month visit
- A 3 kg weight loss in the first 6 months qualifies for extra face-to-face visits.
- Reassess readiness to change and BMI after 6 months if 3 kg weight loss isn't achieved initially.
Frequency
Medicare covers up to 22 visits with G0447 and G0473 codes combined in 12 months:
- First month: 1 face-to-face visit every week
- Months 2–6: 1 face-to-face visit every other week
- Months 7–12: 1 face-to-face visit every month if patient meets certain requirements
ICD-10 Codes
Use appropriate Diagnosis codes (Z68.3 Body mass index [BMI] 30-39, adult) which denote BMI > 30. This service cannot be billed for patients that have BMI < 30
Intensive Behavioral Therapy (IBT) for cardiovascular disease (CVD) HCPCS & CPT Codes
G0446 — Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
Frequency: Annually
Cardiovascular Disease Screening Tests
80061 — Lipid panel This panel must include the following:
- 82465 — Cholesterol, serum, total
- 83718 — Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
- 84478 — Triglycerides
ICD-10 Codes
Diagnosis code Z13.6 - Encounter for screening for cardiovascular disorders is used with these tests.
Diabetes Screening Tests
82947 — Glucose; quantitative, blood (except reagent strip)
82950 — Glucose; post glucose dose (includes glucose)
82951 — Glucose; tolerance test (GTT), 3 specimens (includes glucose)
ICD-10 Code Z13.1 - Encounter for screening for diabetes mellitus is used with these tests.
Counseling to Prevent Tobacco Use HCPCS & CPT Codes
99406 — Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 — Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
ICD-10 Codes
F17.210 - F17.299, T65.211A - T65.294A, Z87.891 are used to denote current or history of tobacco use in any form.
Medicare Covers Outpatient and hospitalized patients with Medicare Part B who meet these criteria:
- Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
- Are competent and alert during counseling
- A qualified physician or other Medicare-recognized practitioner provides counseling
- Frequency
- 2 cessation attempts per year
- Up to 8 smoking cessation sessions per year, with a maximum of 4 per attempt.
- Next-year sessions start 1 month after the initial visit.
Bottom Line
The annual visit includes common screening and counseling services. Payers often deny these services due to minor, easily avoidable mistakes. Most of the denial objections include
- Missing the designated ICD-10 codes that represent the service
- Exceeding service frequency limits is a common reason for denials.
- Although performing these services, it lacks documentation
- Billing different combinations of services that the payer might not accept. That’s why….
- Schedule and space services with patients to ensure proper timing.
- Forming a simple Checklist of these services or creating timers on your EHR can be a HUGE help!
- E/M visits with the Annual visit (using Modifier 25) must be distinct and significant. The E/M visit must demonstrate medical necessity, addressing a new or existing issue on the same day as the AWV.
AltuMED is a Healthcare Revenue Cycle Management technology and solutions company. Our technologically advanced Practice Management Software, PracticeFit optimizes the Medical Billing workflows for Medical Practices, Labs and Third-Party Medical Billing Companies helping them collect maximum revenue. Find out more.
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