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What are the CPT Codes for Primary Care?

• January 10, 2024
• CPT Codes for Primary Care?

Have you ever wondered what hidden language your doctor uses to bill for primary care visits?

Well, you are not alone! Understanding the Common Procedural Terminology (CPT) codes for primary care is like having a cheat sheet for managing the healthcare billing system. In this blog article, we’ll review the most common CPT codes for primary care appointments – think of it your personal Primary Care CPT Code Cheat Sheet.  Whether you’re a patient looking for information about your medical bills or a healthcare professional needing a quick reference, we have you covered. Let’s understand those codes and provide you with knowledge of what happens behind the scenes during your primary care visits. 

Looking for more information about mental health billing? Check out CPT Codes For Mental Health Psychotherapy Services to see how these codes help manage mental health services.

Understanding of the CPT Coding System

Overview of current procedural terminology (cpt).

CPT billing codes for primary care are like labels for different medical procedures. It’s a system that helps doctors and insurance companies communicate about the services provided during a visit. These codes make it easier to understand what treatments or tests were done. They are a standardised language for medical procedures, ensuring accurate communication between healthcare providers and insurers.

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Purpose and Use of CPT Codes in Primary Care

CPT codes are extremely important in medical billing and coding. These codes are used to generate billing for doctors’ essential care services. When you read these numbers on your account, they refer to your precise medical treatments or services. CPT codes are used in medical billing and coding services to ensure that healthcare practitioners are properly compensated. It functions as a global language, allowing everyone in the healthcare system to comprehend what occurred during your visit and ensuring appropriate pay for services given.

Here’s the List of CPT Billing Codes for Primary Care

Office visit codes.

Office visit codes, such as 99202-99205 and 99211-99215, are CPT codes for primary care. These codes are like tags used to bill for the evaluation and management services. They help describe how complicated the visit was, with lower codes for simpler visits and higher codes for more complex ones. Codes like 99211 and 99212 are for minor services, while 99213-99215 and 99202-99205 are for visits needing more thorough examination and decision-making. Doctors should document the visit’s complexity well to ensure correct reimbursement and reduce the chances of audits or denials in medical billing and coding services.

Preventive Visits Codes

Preventive care visits are a big part of doctor visits for check-ups. When doctors want to get paid for these visits, they use CPT billing codes for primary care. The codes in the range 99391 – 99397 are like labels for different preventive services, such as yearly check-ups. The code used depends on the patient’s age and the complexity of the visit. These codes cover physical exams, health screenings, shots, and advice on healthy living. The medical billing and coding company must document everything accurately to ensure the doctor gets paid the right amount for these crucial preventive care services.

Special Primary Care CPT Codes 

These labels are commonly used in primary care to describe various diagnostic, screening, and treatment procedures. These codes, like 93306 for echocardiography or 93880 for vascular ultrasound, help doctors specify their services. In medical billing and coding, a company uses codes, such as 76705 for abdominal ultrasound or 93005 for an electrocardiogram, to create accurate bills for the care you receive. Some common CPT codes for primary care include 94640 for nebulizer treatment and 81025 for urinalysis.

Lab Testing Codes

Lab testing codes are like labels for medical tests that doctors commonly order. For example, code 83036 checks haemoglobin A1c, which helps monitor blood sugar levels in people with diabetes. Code 85025 is for a complete blood count (CBC), a standard test for overall health. Code 80053 covers a comprehensive metabolic panel and details kidney and liver function. There are also codes for thyroid and lipid panel tests and infectious disease screenings. These codes are crucial for accurate billing and reimbursement in medical billing and coding for primary care. They help the medical billing and coding company ensure proper payment and effective patient care.

Codes Preventive Medicine Services

Doctors use specific codes, like 99381-99387, for preventive care services from infancy to adulthood. Primary care providers, like family doctors, use these codes to bill for preventive care, not diagnose or treat issues. These codes show a detailed checkup and management for different age groups. Services may include a thorough medical history, physical exams, counselling, risk-reduction advice, and screenings for medical conditions. It’s crucial to document everything properly to ensure doctors get paid correctly. This process is part of medical billing and coding, often handled by a medical billing and coding company , ensuring accurate reimbursement for the provided preventive care services.

Vaccination Codes

These are the codes for vaccines in medical billing. For the human papillomavirus (HPV) vaccine, doctors use CPT code 90649. If you got the meningococcal vaccine, it’s coded as 90736. The influenza vaccine has its code, which is 90636. The hepatitis B vaccine is represented by CPT code 90733. The pneumococcal vaccine uses CPT codes 90632 and 90732. The Rotavirus vaccine is coded as 90691, and the zoster vaccine has code 90746. The measles, mumps, and rubella (MMR) vaccines are under CPT code 90707, while the tetanus, diphtheria, and pertussis (Tdap) vaccines are coded as 90713. Various vaccines, like MMR and Tdap, fall under CPT code 90715. Lastly, the high-dose formulation of the influenza virus vaccine has CPT code 90656.

These codes enable doctors and medical billing and coding companies to bill correctly for vaccines administered during primary care appointments. They guarantee that the correct information is communicated for proper invoicing and payment.

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Final Thoughts

We conclude that, knowing the most common CPT codes for primary care is crucial for getting medical bills right. Primary care doctors need to understand these codes and what details are needed for each. This helps them bill accurately and avoid problems like audits or denials. There are different codes for various things, like office visits, lab tests, preventive services, special primary care procedures, and vaccinations. It’s super important to use the right code for each service. By following the guidelines and tips for billing with these codes, primary care doctors can make sure they get paid correctly for their services. 

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

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The noob-friendly guide to medical billing and coding for primary care.

Should you use 99213 or 99214 for your patient visit?

Most primary care clinicians don’t fully understand all the nuances they must consider when determining how to code for billing  for an office visit. Many leave money on the table and “undercode” for fear of being flagged or audited by CMS or commercial payers. While no reputable healthcare practitioner would purposefully commit billing fraud or abuse, no one wants to end up paying fines or facing legal allegations for unintentional violations. However, when it comes to medical billing, payers might not be able to differentiate between innocent mistakes and deliberate missteps.

Medical billing and coding is not taught in medical school and is only briefly reviewed during residency training. With an emphasis on outpatient primary care, the basic review below is a good guide for new or in-training physicians and a great refresher for seasoned clinicians.

Here is everything you will learn in this guide:

• Different types of office visits
• Elements of medical documentation
• How to determine the level of complexity of a visit
• Complexity of medical decision-making
• Other billable services

1. Different Types of Office Visits

When billing for an outpatient visit, you need to know whether you have a new or an established patient. If someone has been in your office for a visit at least once during the last three years, then they are an established patient; otherwise they are considered a new patient.

If you are in a multi-specialty group, a new patient is one who  has not been seen by a healthcare professional in your department in the last three years.

2. Elements of Medical Documentation

The Current Procedural Terminology (CPT) code range for Evaluation and Management (E/M) Services 99201-99499 is a medical code set maintained by the American Medical Association.

Several components of your documentation are used to define the level of the visit or E/M service you provide. Although there are up to five levels, a primary care clinician typically uses the highest three (i.e., 99213, 99214, rarely 99215 if it is an established patient, or 99202 and 99203 if it is a new patient. See table 1.).

There are several elements of medical documentation, but the key components are history, exam and medical decision-making (Table 2). Time is one element that can be used supplementally to determine the appropriate E/M service level, especially when documentation alone won’t reflect the amount of work that level of service requires.  An example would be if a patient came in for a single problem but you spent a significant amount of time providing counseling or coordinating care.

Face-to-face time, for documentation purposes, is the actual time spent with the patient. However, most clinicians spend some time before the visit reviewing the chart and after the visit completing the visit note. According to the CPT Professional 2020 , the face-to-face time associated with the services described by any E/M code is a valid proxy for the total work done before, during and after the visit.

Some clinicians could be tempted to  bill based on time for all their visits so they can bypass all the onerous medical documentation requirements. However, time-based billing is only appropriate when more than 50 percent of the encounter (face-to-face time) was spent on counseling or coordination of care. Having a good understanding of how to code and document properly can work in your favor, because sometimes billing for the actual complexity of the visit can result in a higher level of compensation. 

3. How to Determine Level of Complexity of a Visit

As mentioned earlier, three key components of your documentation determine the E/M service level for an outpatient visit: history, exam and medical decision-making.

Determining the level of complexity is complex, but we will do our best to simplify it. Each of these key components hase a subset of elements that determine the extent of the history and examination as well as the complexity of the medical decision-making. 

The extent of the history and exam can be problem-focused, expanded problem-focused, detailed or comprehensive, while the complexity of the medical decision-making can be straightforward, low-complexity, moderate complexity or high-complexity (Table 4).

The type of history depends on the extent of elements obtained during the visit (CC, HPI, ROS, PMHx, PSHx, FHx, SHx). For example, a problem-focused or expanded problem-focused history would only include a single problem with these elements: CC, HPI, +/- ROS (i.e., a patient with a cold). A detailed history would include chief complaint, extended history of present illness, extended review of systes and pertinent past medical, family or social history. (See table 5.)

If you have a patient with three problems (for example, diabetes, hypertension and hyperlipidemia), your documentation for the history component most likely will be detailed enough. Per CMS documentation guidelines , an extended HPI should describe at least four elements of the present HPI or the status of at least three chronic conditions.

The elements of the HPI are the descriptors of a medical problem. Think of the old mnemonic OPQRST (onset, provocative factors, quality/quantity, radiation, severity, timing). For example, the following HPI has four elements and would qualify as an extended HPI.

Since you need to a complete review of systems (more than ten systems) to be able to meet the criteria for a comprehensive history, some clinicians, to get more “points” into the history component, type something like this: “All systems reviewed and negative except for pertinent positives in history of present illness.” or “10/14 review of systems completed and were negative except as stated above in HPI.” These kinds of statements are unnecessary. Is very rare for a clinician to review more than ten systems in a visit. Also, you only need to review two systems to bill a 99214 or 99203. A decent documentation of your HPI most likely will satisfy the requirements for a detailed history.

Most EHRs automatically include some past medical, family and social history into the note, typically in a section different from the HPI. However, it doesn’t matter if the ROS and past history are included in or outside  the HPI section.

 A comprehensive examination involves a general multi-system examination or complete examination of a single organ system. It is fairly easy to document a comprehensive exam using StatNote ’s no-touch exam template, because everything can be gathered from entering the room, greeting the patient and shaking their hand. 

This template covers nine organ systems or elements required for a comprehensive exam. You could then revise the template or add pertinent findings to it.

Medical Decision-Making

We now know that each of the three key components have specific elements that are taken into account to determine the type of history or exam and the complexity of the medical decision-making. Determining the complexity of your decision-making is the most important part of the process since it will ultimately dictate the level of the visit.

The CMS’s Patients Over Paperwork initiative streamlines regulations to reduce burden and increase efficiency. Effective January 1, 2021, practitioners will have the choice to document office/outpatient E/M visits via medical decision-making or time. In other words, if you feel frustrated about all the complexity it takes to determine the type history and exam, in 2021 you will need to focus only on the medical decision-making to determine the level of your visit.

A new patient must meet or exceed all of the three key components required to qualify for a particular level of E/M service, while an established patient must meet only two of the three. (I.e., you could bill for a 99215 for an established patient visit if you documented a complex exam and a high-complexity medical decision, even if your history is just problem-focused. However, to bill for a 99205 for a new patient, you will need all three key components: a complex history, a complex exam and a high-complexity medical decision.)

4. Complexity of Medical Decision-Making

Medical decision-making depends on three elements: 

• The number of diagnoses or management options.
• The amount and/or complexity of data to be reviewed (medical records, diagnostic tests).
• The risk of significant complications, morbidity and/or mortality associated with the patient’s problem(s). 

To reach a level of medical decision-making, two of the three elements must either be met or be exceeded according to the next table of progression.

Indicators of complexity

• Undiagnosed problem > identified problem.
• Number of diagnostic tests. +++ > +
• Problems that are worsening or failing to change as expected > Problems that are improving or resolving.
• Need for a consult from specialist > No need for consult.

That is why coding experts will tell you to document the MEAT for each diagnosis in your note. MEAT stands for the following: 

• Monitor disease progression 
• Evaluate test results or response to treatment
• Assess or address ordering tests, discussion, counseling
• Treatment documentation (medications, therapies).

Since only two out of three elements must be met to reach a MDM level of complexity, let’s focus on the number of diagnoses and risk. For data reviewed, just keep in mind documenting labs or imaging ordered and, if reviewed, comment on the findings (for example, “WBC elevated” or “CXR unremarkable”). Document when medical records were requested and note when history was obtained from sources other than the patient (for example, family, caretaker or other medical records). Also document the relevant information obtained.

The level of risk of complications, morbidity and mortality can be minimal, low, moderate or high. This is based on the risks associated with these categories:

• Presenting problem(s)
• Diagnostic procedure(s)
• Possible management options.

Let’s go through a few examples pertinent to primary care. You can find a more comprehensive table of risks here: CMS documentation guideline (page 18). 

Minimal risk

A patient with a self-limited or minor problem.

• A mosquito bite.
• Patient with a cold managed with rest and gargles.

Acute uncomplicated illness or injury needing over-the-counter drugs.

• Ankle sprain treated with ibuprofen.
• Allergic rhinitis treated with nasal fluticasone spray.

One stable chronic illness.

• Well-controlled diabetes or hypertension.

Two or more self-limited or minor problems.

Moderate-risk

One or more chronic illnesses with mild exacerbation, progression or side effects to treatment.

• Uncontrolled diabetes.
• Patient with hypertension who develops side effects to Amlodipine.

Two or more stable chronic illnesses.

• Visit for diabetes and hypertension.

Acute uncomplicated illness needing prescription drug management.

• UTI treated with antibiotics.
• Dermatitis needing a prescription for topical triamcinolone.

One or more chronic illnesses with severe exacerbation.

An acute or chronic illness that poses a threat to life or bodily function (possibly any patient you see in your office that needs to go to the ED).

• Diabetes with severe hyperglycemia or DKA.
• Patient with neurologic symptoms, needing to r/o stroke.
• Patient with chest pain suspecting MI.
• Patient with RLQ abdominal pain and fever, suspecting appendicitis. 

The AAFP offers this reference card that assigns a point system to each key component-specific element of the medical documentation to ensure that the documentation meets criteria for a 99214 visit. It also details the differences in documentation requirements for level 4 visits with new and established patients.

5. Examples

Now that we understand all the elements that go into determining the appropriate billing code let’s review a few examples of the most common E/M codes. You can go back to table 6 to review the required key components.

Remember that new patient visits require three out of three key components (history, exam, MDM) and established patients only require two out of three. To oversimplify the concept, you could think that a 99213 would be equivalent to a 99202, 99214 equivalent to a 99203, and a 99215 equivalent to a 99204. (See figure 1.)

Progress note 1 – URI

MDM is low: an acute illness treated with over-the-counter drugs. The exam is detailed (even though only an EPF exam is required). The HPI is EPF.

If this was an established patient, it would meet criteria for a 99213 visit. (Check table 6). If this was a new patient, it would qualify only for a 99202 visit. 

99213 – Established patient: Low complexity MDM. EPF history or EPF exam. (only two out of three key components required) .

99202 – New patient: Straightforward MDM. EPF history and EPF exam. (Three out of three key components required) .

It could qualify for a 99203 if you had a detailed HPI, which would require a full past medical, social and family history (which most likely you don’t have since it’s a new patient) and a complete ROS. 

For the sake of argument, let’s say that this is a new patient only because it is new to your department but another doctor in your multi-specialty group has already documented the patient’s medical, social and family history. Assuming that your EHR automatically added all the past medical history to the note (PMHx, FHX, SHx, etc), you would still need to review ten organ systems. In this patient with a common cold, a review of two organ systems would be sufficient (constitutional and respiratory). You could add a complete review of systems to meet criteria for a detailed HPI; however, that would probably be a stretch.

Progress note 2 – DM/HTN/HLD

MDM is moderate complexity: three stable chronic illnesses. The exam is comprehensive. The history is detailed.

99214 – Established patient: Moderate complexity MDM. Detailed history or detailed exam. (only two out of three key components required).

99203 – New patient: Low complexity MDM. Detailed history and detailed exam. (Three out of three key components required).

Even though we have a moderate-complexity MDM in this patient with three chronic problems and we have a detailed history, we cannot bill for a 99204 because we don’t have a comprehensive history.

Progress note 3 – uncontrolled hypertension

MDM is moderate given the moderate risk of complications. In this case, the patient has a chronic condition with mild progression or exacerbation. If it was an hypertension emergency, the MDM complexity would be high given the high risk of complications, morbidity and mortality.

This note would qualify for a 99214 or 99203, depending whether it is an established or new patient.

Progress note 4 – chest pain

MDM is high complexity: an acute illness that may pose a threat to life or bodily function. This patient may be having an MI.

In this and all the previous notes, we used a comprehensive exam. As previously mentioned, you can ensure that you have a comprehensive exam by using a template that you then edit according to your findings. This way you can focus on two key components of your documentation: history and MDM. 

99215 – Established patient: High-complexity MDM. Comprehensive history and comprehensive exam.

99204 – New patient: Moderate-complexity MDM. Comprehensive history and comprehensive exam.

If this was an established patient, even though we don’t have a comprehensive history, we do have a comprehensive exam and high-complexity MDM (2/3).

If this was a new patient, it wouldn’t meet criteria for a 99204 or 99205 visit because you wouldn’t have a comprehensive history. This would require an extensive HPI, a complete ROS and complete past medical history. However, if you spent 45 minutes or more with the patient you could bill based on time as long as you document something along these lines:

Total encounter time was 45 minutes with more than 50 percent of the visit involved in counseling/coordination of care. An EKG revealed ischemic changes and an ambulance was called, EMS took the patient to the ED and I personally discussed the case with the ED physician.

6. Other billable services

Other services you can bill for include the following:

• Preventive medicine services
• Counseling services
• Nursing home visits
• Home visits
• Telephone services
• Telehealth visits
• Online medical evaluation
• Work-related or medical disability exams
• Care plan oversight
• Cognitive assessments
• Chronic care management services
• Transitional care management services
• Advance care planning

Don’t limit yourself to billing only for 99213s and 99214s. In our next article, we will explore all your options. Chances are that you are already providing some of these services, but you might not be documenting or billing for it.

You can also find more dot phrases and commonly used CPT codes in our book. Get it today for free on Amazon using kindle unlimited.

Final Thoughts

Don’t forget to subscribe to our blog and our YouTube channel for interesting articles and videos.

What other billing and coding tips do you use? Feel free to share. Comment below.

Discover Chartnote – We are passionate about preventing physician burnout by decreasing the burden of medical documentation.

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Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account:  chartnote.com

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Don’t limit yourself to billing only for 99213s and 99214s. In our next article, we will explore all your options (where is the link for the next article?). Thanks.

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Understanding Primary Care CPT Codes

Navigating the world of medical billing codes can be overwhelming, especially for those in the primary care field. There are several primary care Current Procedural Terminology (CPT) codes used to describe the various services and procedures offered to patients. These codes are crucial for billing and reimbursement purposes, and understanding them is vital for the success of any medical practice. In this article, we will take a closer look at the different primary care CPT codes, including office visit codes, preventive visit codes, preventive medicine services codes, special primary care CPT codes, lab testing codes, and vaccinations codes.

1. Office Visit Codes (99202-99205 & 99211-99215)

The primary care CPT codes 99211-99215 and 99202-99205 are used to bill for evaluation and management services provided in an office or other outpatient setting. These codes are differentiated based on the complexity of the visit, with lower level codes used for less complex visits and higher level codes used for more complex visits. The codes 99211 and 99212 are typically used for minor medical services that do not require the presence of a physician, while codes 99213-99215 and 99202-99205 are used for visits that require medically appropriate history and/or examination, and varying levels of medical decision-making. It is important for providers to accurately document the complexity of the visit to ensure appropriate reimbursement and minimize the risk of audits or denials.

2. Preventive Visits Codes (99391 – 99397)

Preventive care visits are an important aspect of primary care, and there are several CPT codes that are used to bill for these services. The CPT code range for preventive visits is 99391 – 99397. These codes are used for preventive services, such as annual wellness exams, that are aimed at maintaining and improving the patient’s overall health and well-being. The specific code used depends on the patient’s age and the complexity of the visit. These codes may cover a range of services, including physical exams, health screenings, immunizations, and counseling on healthy lifestyle choices. Accurate documentation of the services provided and the medical decision-making involved is critical to ensure appropriate reimbursement for these important preventive care services.

3. Preventive Medicine Services Codes (99381 – 99387)

CPT code range 99381-99387 represents preventive medicine services for patients of different ages, ranging from infancy to adulthood. These codes are used by primary care providers, such as family physicians, to provide preventive care services to their patients. It is important to note that these codes should only be used for preventive medicine services and not for diagnostic or therapeutic services. These codes are used to report comprehensive, age-specific preventive medicine evaluations and management of an individual patient. The services included in this range of codes may include a comprehensive medical history and physical examination, age-appropriate counseling and risk-factor reduction interventions, and screening for various medical conditions. Proper documentation is necessary to ensure accurate billing and reimbursement for these services.

4. Special Primary Care CPT Codes (93306, 93880, 93923, 76705, 93005, 94640, 87804, 94375, 81025, 87880, 92551, 81000, 99173)

The special primary care CPT codes refer to a set of codes that are commonly used in primary care settings to describe a range of diagnostic, screening, and therapeutic procedures. These codes include 93306 for echocardiography, 93880 for vascular ultrasound, 93923 for peripheral arterial studies, 76705 for abdominal ultrasound, 93005 for electrocardiogram, 94640 for nebulizer treatment, 87804 for infectious agent detection by nucleic acid, 94375 for breath carbon monoxide analysis, 81025 for urinalysis, 87880 for infectious agent detection by immunoassay, 92551 for pure tone audiometry, 81000 for urine pregnancy test, and 99173 for vision screening. Understanding the appropriate use and documentation requirements for each of these codes is essential for accurate billing and reimbursement in primary care settings.

5. Lab Testing Codes (83036, 85025, 80053, 84439, 80061, 80076, 84153, 84443, 87880, 87804, 82306, 83704, 86900, 88142, 84481, 86003)

These lab testing codes cover a wide range of diagnostic tests and procedures that are commonly ordered by healthcare providers. Code 83036 covers the measurement of Hemoglobin A1c, which is commonly used to monitor blood sugar levels in patients with diabetes. Code 85025 covers the complete blood count (CBC), which is a standard blood test that provides information about a patient’s overall health status. Code 80053 covers a comprehensive metabolic panel, which provides information about kidney function, liver function, and electrolyte balance. Other codes cover tests such as thyroid function tests, lipid panel tests, and infectious disease screening tests. Accurate coding and documentation of these tests is important for proper billing and reimbursement, as well as for effective patient care.

6. Vaccinations Codes (90649, 90736, 90636, 90733, 90632, 90691, 90732, 90746, 90707, 90713, 90715, 90656)

These are common vaccine CPT codes used in medical billing. CPT code 90649 is used for the human papillomavirus (HPV) vaccine, while CPT code 90736 is used for the meningococcal vaccine. CPT code 90636 is used for the influenza vaccine, while CPT code 90733 is used for the hepatitis B vaccine. CPT code 90632 is used for the pneumococcal vaccine, and CPT code 90691 is used for the rotavirus vaccine. CPT code 90732 is used for the pneumococcal vaccine, and CPT code 90746 is used for the zoster vaccine. CPT code 90707 is used for the measles, mumps, and rubella (MMR) vaccine, while CPT code 90713 is used for the tetanus, diphtheria, and pertussis (Tdap) vaccine. CPT code 90715 is used for various vaccines, including the MMR and Tdap vaccines. Finally, CPT code 90656 is used for the influenza virus vaccine, high dose formulation.

In conclusion, understanding primary care CPT codes is essential for accurate and appropriate medical billing. Primary care physicians need to be familiar with the primary care CPT codes and the documentation requirements for each code to ensure that they are billing correctly and avoiding potential audits or denials. From office visit codes to lab testing codes, preventive medicine services codes, special primary care CPT codes, and vaccinations codes, each code serves a specific purpose, and it is vital to use the appropriate code for each service provided. By following the billing guidelines and tips for each code, primary care physicians can ensure proper reimbursement for their services, while providing the best possible care for their patients.

Due to the fact that CPT is a registered trademark of the American Medical Association , we are unable to provide a complete list of CPT descriptions and guidelines. We have provided this information solely for reference purposes for healthcare providers, and we strongly advise that providers adhere to the appropriate billing guidelines to ensure accurate and compliant billing practices.

About Medisys Data Solutions (MDS)

Medisys Data Solutions (MDS) is a leading healthcare revenue cycle management company that provides reliable and efficient billing services for primary care practices. With a team of experienced medical billing professionals, Medisys Data Solutions understands the complex coding and billing requirements of primary care services, including office visits, preventive medicine services, special primary care CPT codes, lab testing, and vaccinations. We are committed to maximizing revenue for primary care practices while minimizing administrative burden and improving cash flow. Primary care practices can rely on Medisys Data Solutions for their billing needs and focus on providing quality patient care. To know more about our primary care billing services, contact at [email protected] / 888-720-8884

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In the exam room, the distinction between one type of visit and another isn't always clear. It's important to know when — and how — you can bill for both .

BETSY NICOLETTI, MS, CPC, AND VINITA MAGOON, DO, JD, MBA, MPH, CMQ

Fam Pract Manag. 2022;29(1):15-20

Author disclosures: no relevant financial relationships.

In family medicine, it's common for a medical problem to crop up during a routine preventive visit, or for a preventive service to crop up during a problem-oriented visit. For example, let's say you're finishing up a Medicare annual wellness visit when the patient lifts his shirt and says, “Oh yeah, I'd also like you to look at this rash,” which results in a prescription. Or, at a follow-up visit for a patient's chronic condition, you notice he is overdue for a flu shot and colorectal screening, so you perform a preventive visit too.

From a coding perspective, there is a bright line between a preventive medicine visit and a problem-oriented visit. One is for promoting health and wellness, and the other is for addressing an acute or chronic medical problem. But in the exam room, the distinction isn't always clear. The question for family physicians is this: When does the work in the exam room warrant billing for two distinct services?

The answer lies in knowing the requirements for various preventive medicine and Medicare wellness visits, knowing when you've done enough beyond those requirements to also bill for a separate E/M service, and knowing how to document and code it all. The good news is the 2021 E/M coding changes made it easier than it used to be.

When physicians and other clinicians address a medical problem during a preventive or wellness visit, they can often bill for both services.

Knowing the core components of preventive or wellness visits can help physicians recognize when they have done enough work beyond those requirements to bill for a separate evaluation and management service.

Because preventive and wellness visits come with no cost sharing, it's best practice to explain to patients that a separate service performed during the same visit may result in a charge to them.

PREVENTIVE MEDICINE VISITS

Preventive medicine visits (CPT codes 99381-99397) are for patients covered by commercial insurance, Medicaid plans, and some Medicare Advantage plans. Patients value these visits because they are not subject to co-pays and deductibles. After age two, one preventive visit is covered annually.

According to CPT, preventive medicine visits are “comprehensive preventive medicine evaluation and management services of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”

Codes 99381-99387 are for new patients and 99391-99397 are for established patients. Both are further broken down by age group. The extent of the exam, the content of the counseling and anticipatory guidance, and the recommended screenings and immunizations vary depending on the patient's age and gender. “Comprehensive” in the CPT definition is not synonymous with the comprehensive exam required in other E/M services. This is a common misconception among physicians and patients alike.

CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care. But insignificant problems that do not require extra work should not be billed as office visits. If a patient comes in for a preventive visit and the clinician also looks at a rash or notices the patient's blood pressure is elevated, these observations alone are not enough to bill a problem-oriented E/M visit. There must be some medical decision making (MDM) that occurs, such as prescribing a topical treatment for the rash or choosing not to prescribe a medication for the high blood pressure and instead suggesting the patient change his diet.

Once you've documented your MDM, you can bill an E/M visit using codes 99202-99215 with the preventive medicine visit code. Make sure to add modifier 25 to the E/M code to signal to the payer that two distinct visits were done on the same day.

For more details on when to bill both visits, how to level the E/M portion, and what to include in your documentation, see “ One visit or two? ”

ONE VISIT OR TWO?

Medicare wellness visits.

Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits. However, a Medicare wellness visit and a preventive visit should not be billed on the same date of service. Medicare developed the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare” visit) (G0402) and initial and subsequent annual wellness visits (G0438 and G0439) to encourage Medicare patients to receive screenings and preventive care, and to work with their physicians to develop a personalized prevention plan. 1 The requirements are slightly different for the three codes, but in general they require collecting or updating medical, family, and social history; screening for depression; evaluating the patient's ability to perform activities of daily living; assessing the patient's safety at home; recording vital signs; asking about opioid and substance use; and providing guidance about preventive services and a personalized prevention plan (for more details, see the table in “ Medicare 101: Navigating the Rules for Coverage and Benefits in Clinical Practice ”). Similar to CPT's preventive medicine visits, Medicare wellness visits do not require a full head-to-toe physical exam.

The assessment and management of acute or chronic problems are not components of the IPPE or annual wellness visits. When that service is medically necessary during a Medicare wellness visit, the physician can also bill for a problem-oriented E/M office visit on the same day, again using the appropriate CPT code (99202-99215) with modifier 25.

SELECTING THE LEVEL OF SERVICE FOR THE E/M CODE

Hopefully you're now familiar with the E/M coding rules that changed in 2021. 2 Performing a problem-oriented E/M service on the same date as a wellness visit adds a layer of complexity when it comes to choosing the level of service for the E/M code. But, as mentioned, the new rules actually make it easier than it was before.

When selecting a code (99202-99215) using the new E/M guidelines for office and outpatient services, physicians may use either total time on the date of the visit or MDM. History and exam are no longer necessary to select the level of service (though they should still be documented to provide the best care). This makes it easier to select a level of service for the problem-oriented visit when it's combined with a wellness or preventive visit because there are fewer overlapping components when coding based on MDM. The E/M service is your assessment and management of an acute or chronic condition, which is not required in either CPT preventive services or Medicare wellness visits.

It's trickier to code the E/M service based on time because you must make sure to only count the time spent managing the problems, not the time spent on the preventive or wellness service. The February 2021 CPT Assistant newsletter was particularly clear on this, stating “if time is used for selection of a level of the office/outpatient E/M code, the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment because time spent performing a service cannot be counted twice. The code for the problem-assessment portion of the encounter will likely be selected based on MDM.” 3 It might make sense to consider MDM-based coding as the best practice when combining E/M visits with wellness visits.

A problem-oriented visit includes the history of the problem and any symptoms or complaints related to it. It may or may not include a physical exam or data review (e.g., notes reviewed, tests ordered, tests reviewed, or independent historian). It includes the evaluation and management of a problem or condition. When these components are documented in addition to the preventive visit, add a problem-oriented visit code. For more on which components are required for which visits, see “ How to credit combined visits .”

Let's look at some examples of when it would be appropriate to bill for a problem-oriented E/M code (CPT 99202-99215) along with a preventive or wellness visit.

Patient 1: A 70-year-old male, established patient with a history of diabetes and hyperlipidemia comes in for a Medicare annual wellness visit. All required components of the wellness visit are completed. The patient then asks for a refill of his diabetes medication. The physician asks the patient if he is taking his medication as prescribed and following the diet recommendations discussed during the last visit. The physician also performs a focused physical exam, discusses medication management for diabetes and hyperlipidemia, and orders maintenance labs. The physician documents her significant review of the patient's problems, bills for the annual wellness visit with code G0439, and adds a 99214 E/M code because she addressed two stable chronic illnesses and performed prescription drug management. She adds modifier 25 to the E/M code.

Patient 2: A 32-year-old female, new patient comes in for a preventive medicine visit required by her employer. The physician completes all requirements for the preventive visit. During the history portion, the patient tells the physician that she has been having some knee pain exacerbated by running. The physician obtains additional history about the pain, examines her knee, tells her to reduce her running until the pain subsides, and gives her a handout on knee exercises. He also recommends she try a knee brace and follow up if the pain does not lessen with rest. The physician documents the extra work done to address the knee issue, then bills code 99385 for an initial preventive medicine visit for a patient age 18–39, along with E/M code 99203 because he addressed one acute, uncomplicated injury. He adds modifier 25 to the E/M code.

Patient 3: A 49-year-old female, established patient comes in for her annual preventive visit. The physician completes all requirements for the preventive visit. The patient then mentions she has been excessively tired recently and has been having trouble sleeping. The physician obtains a detailed history of the problems, does a thorough physical exam, and orders some labs (complete blood count and thyroid-stimulating hormone). The physician documents the extra work, then bills code 99396 for a periodic preventive medicine visit for a patient age 40–64 and E/M code 99213 for addressing two acute illnesses (fatigue and insomnia) and ordering two labs. The physician adds modifier 25 to the E/M code.

WORKFLOW TIPS

It's hard to plan for surprise problems that come up during a preventive or wellness visit. But your staff can help by asking patients up front if they have any other issues that need to be addressed. This step should occur when staff are scheduling or confirming patient visits, allowing you to block off more time if necessary.

Scheduling staff should also be aware that Medicare wellness visits have strict rules about how often they can be billed. They must be separated by at least 12 months from the previous wellness visit. Having staff check eligibility for Medicare wellness visits using the HIPAA Eligibility Transaction System can help you avoid denials. 4 The timeframes for CPT preventive visits are more forgiving; they can be performed once every plan year (usually a calendar year, but some plans vary).

Patients who know their preventive/wellness visit will be covered with no deductible or co-pay may mistakenly assume all services provided during that visit, including E/M, will be no cost to them. It is best to educate patients on the costs associated with a problem-oriented office visit and let them know that performing one with a preventive or wellness visit will result in the same co-pay they would incur if the problem-oriented visit was on a different day. Most patients will accept this, because getting both visits in the same trip is more convenient for them. Posting flyers in the exam rooms or waiting room about the difference between preventive/wellness visits and problem-oriented visits, and the costs associated with each, can also prevent patient dissatisfaction.

Physicians could ask these patients to return for the problem-oriented visit on another day, but if time allows for providing both services at the current visit, it is only fair and reasonable to do so. Knowing the rules for combined visits, and the convenience they offer patients, should give physicians the confidence to bill fully for their services.

The ABCs of the Initial Preventive Physical Examination. Medicare Learning Network. Accessed Nov. 15, 2021. https://www.mvphealthcare.com/wp-content/uploads/download-manager-files/CMS-ABC-Initial-Preventive-Physical-Examination-ICN006904-01-2015.pdf

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

Evaluation and management (E/M) 2021; AMA CPT Assistant . 2021;2:7-8.

HIPAA Eligibility Transaction System (HETS). Centers for Medicare & Medicaid Services. Updated Oct. 25, 2021. Accessed Nov. 15, 2021. https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/hetshelp

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