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Tables for:
Making Sense of Preventive Coding

[Fam Pract Manag 11(4):49-54, 2004. © 2004 American Academy of Family Physicians]


Table 1. The Standard Preventive E/M Service: An Example


A 28-year-old established patient comes to your office for her well-woman examination. You take the patient's interval medical, family and social history and perform a complete review of systems. You also perform a physical examination that includes a blood-pressure check and thyroid, breast, abdominal and pelvic examinations, and you obtain a Pap smear. The patient is on oral contraceptives and has concerns about intermittent break-through bleeding. You counsel the patient regarding alternatives and give her a prescription for a new medication. You also counsel the patient about diet, exercise, substance abuse and sexual activity. Then you send the Pap smear to an outside laboratory that will bill the test directly to the payer. Although the patient has concerns about her current method of birth control, the associated counseling and change in medication is considered part of the preventive medicine service for her age group, so you should submit 99395, "Periodic comprehensive preventive medicine ..., established patient; 18-39 years," and ICD-9 code V72.3, "Gynecological examination."

BillDiagnosis code(s)Procedure code(s)
PatientV72.3 Gynecological examination99395 Preventive service

Table 2. The Preventive Service E/M Visit With a Problem-Oriented Service: An Example


A 52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, "Periodic comprehensive preventive medicine ..., established patient; 40-64 years" and ICD-9 code V70.0, "Routine general medical examination at a health care facility"; and the problem-oriented code that describes the additional work associated with the evaluation of the respiratory complaints with modifier -25 attached, ICD-9 codes 466.0, "Acute bronchitis" and 786.50, "Chest pain" and the appropriate codes for the electrocardiogram and chest X-ray.

BillDiagnosis code(s) Procedure code(s)
PatientV70.0Routine exam99396Preventive service
466.0Acute bronchitis99213-25*Office outpatient E/M service for established patient
786.50Chest pain  
  93000Electrocardiogram
  71020Chest X-ray, PA and lateral

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision making.


Table 3. The Preventive Visit for a Medicare Patient: Examples


A 65-year-old established Medicare patient presents for her annual well-woman exam. Medicare covers the collection of a screening Pap smear and her pelvic exam and clinical breast check for that year. You should submit the following codes (and related charges) to Medicare: G0101 for the pelvic exam and clinical breast check, Q0091 for the collection of the Pap smear specimen and V76.2, "Special screening for malignant neoplasms; cervix"; and the following codes (and related charges) to the patient: 99397, "Periodic comprehensive preventive medicine ... established patient, 65 years and over," and V72.3, "Special investigations and examinations; gynecological examination." The total amount billed and received for this visit should equal your usual charge for an annual exam of $100.

BillDiagnosis code(s)Procedure code(s)Charge
MedicareV76.2Special screening formalignant neoplasms; cervixG0101Pelvic exam and clinical breast check$36.60
Q0091Collection of Pap smear specimen$37.70
PatientV72.3Gynecological examination99397Preventive service$25.70
Total amount billed and received$100.00

An established Medicare patient presents for management of hypertension and preventive services. Medicare covers the full allowable amount for all reported services. You should submit the following codes and related charges to Medicare: G0101 for the pelvic exam and clinical breast check, Q0091 for the collection of the Pap smear specimen and V76.2; and 99213 for the established-patient office visit (with modifier -25 attached) and 401.1, "Essential hypertension, benign." The total amount billed for this visit should be $127.30.

BillDiagnosis code(s)Procedure code(s)Charge
MedicareV76.2Special screening for malignant neoplasms; cervixG0101Pelvic exam and clinical breast check$36.60
Q0091Collection of Pap smear specimen$37.70
401.1Hypertension, benign99213-25*Office visit$53.00
Total amount billed and received$127.30

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision making.


Table 4. The Preventive Counseling Visit: An Example


A 46-year-old established patient, who was seen six months ago for a health maintenance visit, is in overall good health and is within 10 percent of his ideal body weight, comes to your office to discuss a diet and exercise program. The patient is now interested in a regular exercise program and diet to reduce his risk of cardiovascular disease since his 52-year-old brother recently had a heart attack. You spend 15 minutes discussing these issues with him. You should submit the appropriate preventive medicine counseling code for this visit and ICD-9 codes V65.3 and V65.41.

BillDiagnosis code(s)Procedure code(s)
PatientV65.3Dietary surveillance and counseling99401Preventive medicine counseling
V65.41Exercise counseling

Table 5. Medicare's Covered Preventive Services


This table lists some of the preventive screening services that are covered by Medicare. It shows the covered frequency and the associated HCPCS and ICD-9 codes that should be submitted for each service. (For information about other Medicare-covered screening services, go to http://www.medicare.gov/health/overview.asp.)

Screening serviceFrequencyHCPCS codeICD-9 code
Screening pelvic and clinical breast examOnce every 2 years; once every year for high-risk patients*G0101V76.2, V76.47, V76.49 or V15.89
Screening Pap smear Once every 2 years; once every year for high-risk patients*Q0091V76.2, V76.47, V76.49 or V15.89
Digital rectal exam Once every 12 months for patients 50 years or olderG0102V76.44
PSAOnce every 12 months G0103V76.44
Fecal occult blood testOnce every 12 months G0107 G0328V76.41 V76.51

*Medicare's definition of "high risk" includes patients of childbearing age in which cervical or vaginal cancer is or was present or other abnormalities have been found in the preceding three years and patients with one or more of the following high-risk factors for either cervical or vaginal cancer: onset of sexual activity under 16 years of age, five or more sexual partners in a lifetime, history of sexually transmitted diseases (including HIV), fewer than three negative Pap smears within the previous seven years, no Pap smears at all within the previous seven years or prenatal exposure to DES.