For example, V70.0 should be used for a routine general medical examination performed at a health care facility, and V70.3 should be used to identify examinations for administrative purposes, such as marriage and school admission. The ICD-9 codes associated with preventive services are found in the V codes, which describe the reasons for health care encounters other than disease or injury. ![]() It’s also important to link each ICD-9 code to the applicable CPT code on the claim form, especially when preventive and problem-oriented services are provided at the same visit. , 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.Īppropriate ICD-9 codes should be reported on every claim to provide an accurate reflection of the reason a service was provided. You should submit 99396, “Periodic comprehensive preventive medicine. You document both the problem-oriented and the preventive components of the encounter in detail. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. 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. (See the example of a preventive E/M visit with a problem-oriented service, and for more on ICD-9 codes, see “Using diagnostic codes effectively.”)Ī 52-year-old established patient presents for an annual exam. It’s also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services. As long as service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam and the appropriate office visit code (99201-99215) with modifier -25, “Significant, separately identifiable service by the same physician on the same day of the procedure or other service,” attached to the problem-oriented service. When a patient comes into the office for a routine preventive examination and also has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a combination of preventive and problem-oriented care. , established patient 18-39 years,” and ICD-9 code V72.3, “Gynecological examination.” 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. Then you send the Pap smear to an outside laboratory that will bill the test directly to the payer. You also counsel the patient about diet, exercise, substance abuse and sexual activity. ![]() You counsel the patient regarding alternatives and give her a prescription for a new medication. The patient is on oral contraceptives and has concerns about intermittent break-through bleeding. ![]() 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. You take the patient’s interval medical, family and social history and perform a complete review of systems. A 28-year-old established patient comes to your office for her well-woman examination.
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