Primary Preventive Medicine Services Codes – A Guide for Medical Billers and Medical Coders
During a standard routine check-up at your usual Primary Care Physician's office, the doctor may go through any acute or chronic ailments that require attention. However, there is yet another approach that ensures that the patient's health is proactively promoted and potential concerns are addressed in a timely manner.
‘Preventive Care Visits’, as the name itself suggests is a measure to prevent illnesses, diseases, and curb other health problems in the form an annual visit performed most probably by a Primary care physician. In fact, together with routine Evaluation and Management Visits they form the very basis of many office-based practices other than Primary care settings especially including internal and Family medicine. These visits might help identify and highlight health issues before hand in terms of ‘normal’ and ‘abnormal’ findings.
Even if it seems like a little simpler concept on paper, it comes with its little caveats. For this, in this article, we would go like to through some basics of preventive care and how they can be effectively billed and reimbursed through the years without a problem.
Preventive care Coding: What code to use?
Let’s talk about what codes we can use to bill these services, for that we have to go with one of the two options described below 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 (PPS), initial visit
G0439 — Annual wellness visit, includes a personalized prevention plan of service (PPS), 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(s); 30 minutes (list separately in addition to code for the preventive service)
G0514 — Prolonged preventive service(s); each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)
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?
A patient who has just qualified for Medicare Part B is allowed this once-in-a-lifetime benefit within the first 12 months of Medicare eligibility. The subsequent visit has to be performed after surpassing at least 11 months after the initial Visits.
These visits can also include additional services, such as EKG, vaccinations, screening laboratory services, counseling and even management of medical problems. Depending on your specific insurance plan, this type of visit may be called an annual physical, well-child exam, Medicare wellness exam or welcome to Medicare visit.
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 frequently covered in full by various health plans and provides numerous economic and health benefits to the beneficiaries. The healthcare provider may determine which services are most suited to the patient. However, it is crucial to be aware that the insurance plan may compel you to pay some of the costs of your office visit if preventive care is not the major reason for your appointment.
Who can perform these visits?
Any provider who bills E/M services can bill for these visits on an annual basis. In the network, this should include your primary care physician, general practitioner, or a Family Medicine specialist.
Who is eligible for them?
These visits are intended to improve illness prevention and management among patients of all ages and genders. They are available to patients regardless of their present health situation. Preventive Care Visits are not 'problem-oriented,' yet they are incredibly beneficial in catching problems before they become more serious.
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 HCPCs codes are followed by Vaccine CPT codes. For instance, for Administration of pneumococcal vaccine we will HCPCs code G0009 followed by actual pneumococcal vaccine (Product) CPT code e.g., 90671 will used with G0009 for 15- valent (PCV15) Pneumococcal conjugate vaccine. However, don’t forget to add NDC and other required information in 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 covered vaccinations, the Z23 for Encounter for immunization ICD-10 diagnosis is applicable.
Vaccination: Who is Covered/Frequency:
- All Medicare beneficiaries
- Once per influenza season (Medicare covers additional flu shots in medically necessary)
- An initial pneumococcal vaccine to Medicare beneficiaries who never received the vaccine under Medicare Part B
- A different, second pneumococcal vaccine one year after the first vaccine was administered
- Medicare beneficiaries who are currently positive for antibodies for hepatitis B are not eligible for this benefit
Alcohol Misuse Screening & Counseling HCPCS & CPT Codes
Also known as Screening and Behavioral Counseling Interventions 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 of alcohol misuse. Followed by appropriate diagnosis while performing counselling e.g. F10.10 or F10.129 can be used for uncomplicated or unspecified Alcohol abuse.
Medicare Covers Patients with Medicare Part B who:
- Screen positive (misuse alcohol but their levels or alcohol consumption patterns don’t meet alcohol dependence criteria)
- Are competent and alert during counseling
- Get counseling from a qualified primary care physician or other primary care practitioner 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
- Get counseling from a qualified primary care physician or other primary care practitioner in a primary care setting
- Obesity reassessment and weight loss determination is required at a 6-month visit
- If the patient loses at least 3 kg during the first 6 months, they’re eligible for additional face-to-face visits occurring once a month for months 7–12
- For patients who don’t achieve a weight loss of at least 3 kg during the first 6 months, reassess their readiness to change and BMI after an additional 6-month period
Frequency
Medicare reimburse up to 22 visits billed with codes G0447 and G0473, combined, in a 12-month period:
- 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
- Each attempt may include a maximum of 4 intermediate or intensive sessions, with the patient getting up to 8 sessions spread through-out the year
- Subsequent sessions in the next year start after one month the initial visit was performed
Bottom Line
Explained above were the more common services that encompassed screening and counseling interventions done during the annual visit. Most often these simple but important services are denied by payers because of very overlooked and minor mistakes that could have been easily surveyed. Most of the denial objections include
- Missing the designated ICD-10 codes that represent the service
- Crossing the prescribed frequency limitation of the services is one of the most common denials
- Although performing these services, but lacking on documentation
- Billing different combinations of services that the payer might not accept. That’s why….
- It is very important to calendar and schedule these services with the patient, so they are spread out properly
- Forming a simple Checklist of these services or creating timers on your EHR can be a HUGE help!
- Even though E/M Visits are allowed with the Annual visit services (using Modifier 25), it should be noted that it has to be significant and separately identifiable. Meaning the performed E/M Visit should represent its own medical necessity visibly. That could be a unique problem diagnosed on the same day as AWV that needs to be addressed or an older one that needs attention
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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