Preventive Services: How Practices Can Benefit from the Mandate

Betsy Nicoletti, M.S., CPC February 6th, 2012

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One of the regulations in the health care reform bill mandated that groups include first dollar coverage for preventive services

No co-pay and no deductible for preventive services? Great news!  Not all of your patients will have this coverage, of course, but one of the regulations in the health care reform bill mandated that groups which renew their coverage after September 2010 include first dollar coverage (unless they applied for a waiver) for preventive services that have an A or B rating from the US Preventive Task Force.  How can physician practices benefit from this?

Schedule the right visit type:  Many clinicians schedule longer visits for annual exams than for problem-oriented visits.  Schedule the patient for the right type of visit.  Besides giving the patient and clinician the right amount of time for the service, this will flag the clinical staff to remind the patient to get ordered lab tests before the visit.  For patients seen multiple times in a year, consider scheduling this right after a problem-oriented visit.  This will help the clinician focus on preventive care services at the visit.

Verify coverage and benefits before the visit:  Coverage and benefits can be verified on a payer’s website individual by individual or in a batch through your practice management system.  It is easier and cheaper to do batch eligibility checks, 48 hours before the visit.  On-demand eligibility verification is also available, sometimes at a slightly higher fee.

Open up the correct visit template or use the right form:  Clinicians say there’s nothing more frustrating than being half way through a visit and finding out that the patient thinks the visit was for another reason.  This results in visits that run over, as the doctor tries to do it all, or visits billed incorrectly.  The correct visit type in the appointment schedule results in the correct template opened in the EHR or the correct form place on the chart.  The staff member who rooms the patient asks the patients the screening tests, verifies medications and documents changes in past medical, family or social history.  This is a time saver for the clinician.

Bill for immunizations correctly:  There are two components for vaccine billing: the administration and the vaccine.  States provide some vaccines free for certain age patients.  If the practice gets the vaccine for free, bill only for the administration.  If the practice buys the serum, bill both for the vaccine and for the administration.  Medicare uses different codes for the few immunizations they pay. In 2011, the AMA slightly changed the definition of immunization administration.  The CPT definition instructs groups to bill for administration of each component of the vaccine, not per injection.  Review the CPT definition of immunization administration if you haven’t already done it.

Bill for other services performed:  The CPT book states that other screening services performed at the time of the preventive medicine services should be separately reported.  (Reported, the CPT fancy word for billed.)  Screening hearing and the visual acuity test are two examples of this.  The visual acuity test, 99173, is rarely paid separately, despite CPT rules.  Obtaining a screening pap smear may be billed with a HCPCS code, Q0091.   Venipuncture, 36415 may be billed if a screening lab test is done.  Many payers will deny as “incidental” or bundled a finger stick, 36416 or lab handling, 99000.  Some groups submit these services and some don’t take the time to post them.

If you add an office visit on the same day:  CPT allows a clinician to bill for a problem-oriented visit (99201—99215) on the same day as a preventive medicine service.  CPT says if significant extra work was performed that required the key components (history, exam and medical decision making) at the same visit as a preventive service, bill for both in the same day and append modifier 25 to the problem-oriented visit.  The patient will have a co-pay and deductible for the office visit, and can be quite upset to be billed for both services.  If billing for both services, be sure that the history documents the patient’s problems that day.  “Feeling great, playing a lot of golf” doesn’t justify a separate office visit.  Document the patient’s symptoms or the status of their chronic problems.  In the assessment and plan, document the change in the patient’s condition or treatment to support the additional visit.

Oops, it’s a Medicare patient!:  Medicare does not cover the preventive medicine services defined the way CPT defines them using codes 99381—99387.  CMS still says those are routine and non-covered.  You can read another article on this blog about billing for the Annual Wellness Visits and Welcome to Medicare Visit.  Schedule those patients for the correct visit type, and open up the correct template for these Medicare patients.

Betsy Nicoletti will discuss optimizing preventive services in great detail in our upcoming webinarBetsy Nicoletti, M.S., CPC, is the founder of, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at You can hear her speak in an archived webinar on What You Can Do to Prepare for Medicare Payment Reductions. She has also written recently on How Should You Code Pre-Op Exams and Who Can Perform Them?, CPT Changes for 2012: An Overview, and Why Can’t We Get Paid? A Look at Denials.

Be sure to register for our upcoming webinar, Optimizing Office Visits for Preventive Services, featuring Betsy discussing this subject in greater depth.

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