Can you bill a new preventive visit with a new office visit?

Yes, you can bill a preventive visit and a problem-focused office visit on the same day if the provider addresses a significant, separate medical issue.

Key Billing Requirements

• Separate Problem: The condition or abnormality must be significant enough to require additional work beyond the routine preventive exam. Trivial issues do not qualify.
• Modifier 25: You must append Modifier 25 to the problem-focused Evaluation and Management (E/M) office visit code (such as 99211–99215) to indicate a significant, separately identifiable service.
• Documentation: The medical record must clearly separate the documentation for the preventive exam from the evaluation of the acute or chronic problem.
• Time Counting: If using time to select the office visit code, any time spent on the preventive service cannot be double-counted toward the problem-oriented code.

Insurance and Cost Considerations

• Coverage Varies: While coding guidelines permit both charges, commercial insurance policies handle same-day billing differently.
• Patient Costs: Patients may face unexpected out-of-pocket costs, such as a copay, coinsurance, or deductible applied to the office visit portion, even if the preventive portion is fully covered.

Yes, CPT code 99397 (preventive visit for an established patient aged 65 and older) and CPT code 99214 (outpatient evaluation and management for an established patient, moderate complexity) can be billed together only if the provider performs and documents a significant, separately identifiable medical service beyond the routine preventive exam.

Key Billing Requirements

• Modifier -25: You must append modifier -25 to the problem-oriented E/M code (99214) to indicate that the work done for the acute or chronic problem was distinct from the routine preventive service. Do not place the modifier on the preventive code.
• Distinct Documentation: The medical record must contain clear, separate documentation showing the clinical rationale and medical decision-making for both the preventive exam and the separate problem (such as managing an active chronic illness or a new acute complaint).

Important Insurance Considerations

• Payer Rules Differ: While commercial insurances and some Medicare Advantage plans may cover both codes when billed together with proper documentation, traditional Medicare does not cover routine preventive codes like 99397 (instead utilizing G-codes like G0438 or G0439 for Annual Wellness Visits). Always verify specific payer guidelines before submitting.

A preventive care visit is a scheduled medical appointment with your primary care provider when you feel healthy, aimed at preventing illness, updating immunizations, and catching health issues early before symptoms appear. Learn more about what distinguishes a Preventive Visit vs. an Office Visit to understand how your appointment is classified.

What Happens During a Visit

• Medical history review: Discussing your lifestyle, family history, and personal health factors.
• Physical exam: Checking vital signs like height, weight, blood pressure, and listening to your heart and lungs.
• Immunizations: Receiving routine vaccines such as the flu shot, Tdap, or shingles vaccine.
• Age-appropriate screenings: Ordering lab work or tests for cholesterol, blood sugar, diabetes, and cancers (like mammograms or colonoscopies).
• Health counseling: Reviewing ways to reduce risk factors related to diet, exercise, or tobacco use.

What Does NOT Qualify

• Symptom evaluation: Asking a doctor to diagnose or treat a new or existing medical problem.
• Chronic disease management: Adjusting medications or actively treating ongoing conditions like high blood pressure flare-ups or diabetes management during the same visit.
• Diagnostic testing: Taking tests specifically because you have active symptoms or unusual findings on a prior screening.

(Note: If your preventive exam shifts into diagnosing or treating a specific condition, the provider may bill a portion of the visit as an office visit, which can trigger a copay or deductible charge.)

The primary difference between CPT codes 99395 and 99396 is the age bracket of the established patient receiving the comprehensive preventive visit.

Age and Focus Differences

• CPT 99395: Used for an established patient aged 18 to 39 years. The exam focuses on young adult health, lifestyle counseling, reproductive health, and screenings like cervical cancer or sexually transmitted infections (STIs).
• CPT 99396: Used for an established patient aged 40 to 64 years. The exam incorporates middle-aged health maintenance, adding age-specific and cardiovascular screenings such as mammography and colorectal cancer checks.

Shared Similarities

• Patient Status: Both codes apply only to established patients (someone seen by the provider or same group practice within the past three years).
• Service Type: Both represent a periodic, comprehensive preventive medicine evaluation that includes a history, physical examination, counseling, anticipatory guidance, and risk factor reduction.
• Exclusion of Problem Care: Neither code should be used as the primary code if the main purpose of the visit is to treat an acute or chronic illness.

Coding guidelines for preventive services in CPT focus on evaluating overall health and wellness rather than diagnosing or treating acute illnesses or injuries.

Core Code Selection Rules

• New vs. Established: Determine if the patient is new or established. A new patient has not been seen by the physician or another physician of the exact same specialty and group in the past three years.
• Patient Age: Select the specific CPT code based on the exact age of the patient on the date of service.
• New Patient Codes: Use 99381–99387 for initial comprehensive preventive evaluations.
• Established Patient Codes: Use 99391–99397 for periodic comprehensive preventive evaluations.

Key Service Components

• No Chief Complaint: The encounter is for a routine wellness exam, screening, and health evaluation without an active illness focus.
• Required Elements: Includes an age- and gender-appropriate history, a comprehensive physical examination, counseling or anticipatory guidance, risk factor reduction interventions, and ordering appropriate laboratory or diagnostic procedures.
• Not Based on Time or Medical Complexity: Unlike office/outpatient E/M codes (99202–99215), preventive codes are driven strictly by age categories and whether it is an initial or periodic visit.

Handling Co-Existing Medical Problems and Modifiers

• Significant Additional Problems: If a distinct, separate problem-oriented evaluation and management service is performed during the same preventive encounter, append Modifier 25 to the problem-oriented E/M code.
• Documentation: Separate documentation must clearly support both the routine preventive service and the distinct problem-oriented evaluation.
• Diagnosis Codes: Use appropriate ICD-10 Z codes (routine/screening encounters) as the primary diagnosis, placing any co-morbid acute or chronic condition codes secondary if a problem-oriented service is also addressed.
• ACA Requirements: Use Modifier 33 on commercial claims when mandated under the Affordable Care Act for preventive services with zero patient cost-sharing.