Billing for Additional Complaints During the Preventive Examination

By Dina Petrutsas, CPA
Wednesday, December 7, 2016

Are you leaving money on the exam table? Many providers are performing additional services at the patient’s request during the preventive examination and not taking credit for their work.

Dina Petrutsas, CPA

While expenses continue to rise in running a medical practice, the practice manager should ensure providers are documenting all medical care provided to their patients, and then ensuring the claims contain these additional services. If you have a busy family practice, internal medicine practice or OB-GYN practice and have not been billing for additional services performed, you may be pleasantly surprised when you see the revenue being generated for taking credit for what you did.

The Affordable Care Act of 2010 provides for preventive examinations, without any patient cost sharing (copayment or deductible) to encourage patients to obtain preventive services that help them avoid possible chronic conditions in the future. CPT codes 99381 through 99387 are used to code the initial preventive visits, and CPT codes 99391 through 99397 are used to code the periodic preventive visits for an established patient. The documentation and billing rules may vary depending on the patient’s insurance, so it is best to review the insurance payer’s rules and regulations to correctly process these claims.

How many times has a provider performed a preventive service only for the patient to bring up several complaints that are not related to the preventive encounter? These “oh, by the way” complaints take additional time for the encounter, and they can be billed if the provider adequately documents the complaint. The provider should use CPT codes 99201 through 99215, and add Modifier 25, which would then be appended to the office visit level of service reported, to indicate that a significant, separately identifiable E/M service was provided. The actual process to document the entire patient encounter may vary based on the insurance plan’s rules and regulations, as well as if the insurance plan will either (1) pay a full amount for the 99201 through 99215, (2) reduce the payment since it is a second encounter on the same day or (3) perhaps not pay for the additional services at all.

In many cases, the provider does not document the additional complaint, and therefore the service is not included on the claim. Just remember to document what you did for the preventive service and the additional service, and ensure the documentation supports each CPT code. It may be helpful to educate the entire staff about the rules and regulations of billing these types of patient encounters, as well as how your staff should notify the patient of possible additional charges.

Some medical practices have developed a form for patients to review and sign that explains the purpose of their preventive visit, and that there will be additional charges for the visit if the provider performs any medically necessary services at the patient’s request.

Do you need help to better bill for these “oh, by the way” services? Contact Concordis Practice Management today to request a consultation for a coding review and audit.


Contact Concordis Practice Management LLC at 210-704-1014 or visit concordispm.com for more information.