Simplifying Preventive Visit Coding: Best Practices For Cpt 99396

By Author: Charlie Robinson
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Effective coding in healthcare is important, especially in terms of reimbursement and payer policy compliance. Coding for preventive visits may be challenging at times, particularly for CPT code 99396. This is for preventive medicine services for established patients aged between 40 and 64 years. To ease documentation and billing, medical professionals should implement best practices to reduce errors and maximize efficiency. In this blog, we are going to make the basics of CPT 99396 easy to understand, which includes patient criteria, documentation requirements, billing process, and errors to avoid.

Understanding CPT Code 99396

CPT code 99396 is a preventive medicine evaluation and management (E/M) service. Preventive visits vary from problem-based visits as the former addresses health maintenance, disease prevention, and risk assessment rather than complaints.

This service will typically include:

• A comprehensive review of the medical history
• A comprehensive physical examination
• Age- and health-status-appropriate screenings and risk assessments
• Counseling on preventive ...
... care and lifestyle recommendations
• Appropriate vaccinations and lab tests

Key Components of CPT 99396
In order to bill CPT 99396, providers should include the following items:

1. Patient Eligibility
• Returning patients only: CPT 99396 is billed for returning patients between 40-64 years old.
• In case of a new patient, an alternative CPT code (99386) has to be used.

2. Documentation Requirements
Proper documentation is necessary to validate the claim. Providers must document:

• Comprehensive Medical History: History of previous illnesses, family history, current medications, and lifestyle.
• Physical Exam: Comprehensive examination of body systems based on age-related risk factors.
• Preventive Screens: Tests based on age, including blood pressure, cholesterol screening, cancer screenings (e.g., mammogram, colonoscopy), and vaccinations.
• Risk Assessments: Risk assessment for chronic disease based on family and personal history.
• Counseling and Health Education: Exercise, diet, quitting smoking, etc.

3. ICD-10 Diagnosis Codes
To warrant medical necessity, the correct ICD-10 "V" codes need to be used. The codes describe the preventive type of visit. A few more typical ICD-10 codes are:

• Z00.00 - Normal adult medical examination
• Z00.01 - Abnormal findings on the adult medical examination
• Z13.220 - Screening for lipid disorders
• Z12.11 - Screening for malignant neoplasm of the colon

Billing Rules for CPT 99396
Proper billing ensures proper payment. In fact, important things to keep in mind while billing are:

1. Time Requirement
Although CPT 99396 is not time-based, providers are encouraged to report duration of visit where required by some payers. A vast majority of payers expect a comprehensive visit that takes a lot of time.

2. Application of the Modifier
• Modifier 25: If a patient presents with a new or chronic issue that requires more evaluation than preventive care, a separate E/M code can be billed along with modifier 25.
• Modifier 33: If services are fully covered under the Affordable Care Act (ACA) preventive care guidelines, modifier 33 can be applied.

3. Separate Billing for Non-Preventive Services
If the patient has a preventive visit but also requires management of an acute or chronic problem, the physician should bill another E/M code (e.g., 99213, 99214) with modifier 25. The documentation must clearly indicate that the two services were done separately.

4. Payer-Specific Guidelines
Policies on preventive visits vary from insurance payer to insurance payer. Providers should refer to individual payer requirements for coverage, documentation, and bundling rules.

Common Billing Errors and How to Avoid Them
Billing errors can lead to claim denials, payment delays, and compliance problems. Some common errors and how to prevent them are listed below:

• Improper Diagnosis Codes: Preventive visits should always be billed with a correct ICD-10 Z code. When treating an acute condition, place the Z code first, followed by the relevant condition code.
• Failure to Document Preventive Nature of Visit: It is also required to make sure chief complaint contains "preventive visit" or "annual wellness visit" and separate preventive services from problem-oriented care clearly.
• Incorrect Use of Modifiers: In case another problem-focused E/M service is provided, use modifier 25, and document all elements required by CPT 99396 separately from the additional service.
• Upcoding or Downcoding: Avoid billing for a higher level of service than is actually done (upcoding) or a lesser level of service to avoid risk of audit (downcoding).

Why Accurate Coding is Critical?
Proper coding of CPT 99396 assures timely reimbursement, fewer denials, and enhanced patient care. Primary care physicians can allow seamless billing and prevent most errors by proper documentation and payer compliance.

Help Needed with Preventive Visit Coding?
Medical billing can be a headache, but working with experienced billing professionals will make the experience seamless. 24/7 Medical Billing Services specialize in outsourcing medical billing and coding services to help providers optimize reimbursement and maintain compliance.
Therefore, providers can simplify preventive visit coding, reduce claim denials, and optimize efficiency in their practice by following these best practices for CPT 99396. Accurate documentation, accurate use of modifiers, and compliance with payer guidelines are the keys to seamless medical billing and reimbursement processes.

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