Health Assessments, Office Visits and Modifier 25, Oh My!

Many providers find coding Preventive Medicine (Health Assessments) and Office Visits very confusing. In fact, many feel that it is not worth it. It seems simple enough, an established 34-year-old male patient comes in for their annual health assessment and also have other conditions like HTN, Diabetes Mellitus and Hyperthyroidism that were addressed. Why shouldn’t I be able to use a Preventive Medicine code (99395) with at least a low-level established patient visit (99213) and modifier 25?

Well your partially right. See, a Health Assessment is…. well exactly that. It is an assessment of your patients overall health. The extent and focus of the services will largely depend on the age of the patient. When a provider conducts a health assessment it is expected that the provider will chart a comprehensive age and gender appropriate history /exam. At this time I would like to explain the term “comprehensive”. As you may be aware, Office visits have Comprehensive history and exams too. However, Comprehensive in a Health Assessment (99381-99397) is not synonymous with comprehensive exam in an office visit (99201-99215). Meaning, the Nature of the presenting problem dictates the elements in your history, exam and medical decision-making for office visits. In other words, if a patient presents for a splinter on a finger, a comprehensive history and exam should not have to be attained to gather the information, and the medical decision-making should only show the necessary treatment for removing a splinter (Always remember medical necessity). Other important facts about health assessment are anticipatory guidance, risk factor reduction interventions or counseling, and management of insignificant problems.

So, what should you do when you have a patient with an acute condition (chest pain) and/or chronic condition (HTN) presenting for an annual Health Assessment?

You should take a comprehensive history, comprehensive exam and order proper laboratory/diagnostic procedure. Now lets take a look at the acute and/or chronic conditions. Providers should ask themselves if the condition is requiring work up that is over and beyond their usual. Remember, documentation guidelines are not the same for health assessment. In other words, Health Assessments does not rely on a chief complaint or a history of presenting illness. Also, a health assessment is not problem oriented. Health Assessments rely on a comprehensive ROS (Review of Systems), a comprehensive PFSH and a comprehensive assessment of risk factors. Since you already documented a comprehensive history and exam, this would be considered overlapping. Therefore, the E/M reported for the problem visit (99201-99215) should be based on additional work performed by the provider in determining the best course of action in treating this problem.

Ask yourself, can this condition stand on its own? Is this condition significant enough to have its own encounter?

When using an office visit code (99201-99215) with a health assessment (99381-99397), a modifier 25 should be used to show the separately identifiable service that was performed within the annual exam.

Modifier point: Modifier 25 is used to show a significant, separately identifiable evaluation and management, service by the same physician on the same day of the procedure or other service. This modifier can only be appended with an E/M code.

Preventive Medicine Example:

34-year-old male comes in for routine annual visit. Patient is also noted to have HTN. HTN is stable w/ diet and medication. Patient has no complaints. A comprehensive history and exam is taken. Provider orders labs and tells patient to continue with current medication.

S: Patient here for annual follow-up. Patient has HTN. No complaints.

No f/c, chest pain, dyspnea, blurry vision, sore throat, n/v, allergies, lymph abnormalities, thyroid problems, urinary incontinence,

Medical hx: HTN

Family hx: father has DM

Social: non smoker, social drinker, married

O: 130/70, 96.7

HEENT: anicteric sclera, ENT: normal

Cardio: normal RRR

Lungs: Clear to Auscultation

Ext: good ROM, no abrasion, no edema, skin tight

Neck: no lad

Neuro: A&O x3,

GI: soft nontender, normal BS

Gu: Normal

Anticipatory guidance discussed about exercise and medication. Patient indicates understanding

Assessment: health checkup,HTN

Plan: Continue meds as ordered.

Dx(s): V70.0, 401.9

CPT: 99395

Preventive Medicine with office visit example:

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. No f/c, dyspnea on exertion, n/v. Remember, you are going to document additional history to support the exacerbated condition. Your exam is going to still comprehensive for the health assessment with extra documentation of the affected area(s) (Cardiovascular and Respiratory). An EKG and chest X-ray is ordered and reviewed. Your final diagnosis is acute bronchitis and chest pain.

Assessment: health checkup, Acute Bronchitis, Chest pain

Plan: Medication for Acute Bronchitis is prescribed.

Dx(s): V70.0, 466.0

CPT: 99397 (Health Assessment)

99213(Problem visit) -25 (Significant, separately identifiable service by same provider on same day)

93000 (EKG)

71020 (Chest xray, PA and lateral)

Please note, the above cases are examples only. As with all documentation, providers should always report the correct level of service by the documented history, exam and medical decision making. To find more examples of using preventive medicine codes with and without office visits, go to your respective medical societies; AAFP, ACOG, etc… They are ALWAYS a great resource for information!

Tal’Mai Chester is an independent consultant and owner of Chester Billing Group. Mrs. Chester has been in the Health Information field for several years. Mrs. Chester is certified through AAPC (American Academy of Professional Coders) as a CPC and CPMA. She is also an approved ICD-10 cm/pcs Trainer through AHIMA (American Health Information Management Association) and a member of HCCA (Health Care Compliance Association).

What Is a Health Assessment?

Too many people go through life only visiting a doctor when they are ill. However, doctors can help you when you’re not ill in the form of a general check-up. In some countries, it’s perfectly normal to visit your doctor every year for a check-up, in order to ensure that your body is working as it’s supposed to. In the UK, the NHS manages a high demand for GPs, so diagnosis and treatment is given priority. That’s why many people with the means to do so turn to private hospitals, getting a health assessment for their own peace of mind. But what exactly is a health assessment and what does it involve?

Essentially, a health assessment is a general check-up on the health of your body. It involves tests that can take from an hour to all day, which will tell you about the general state of your health and help you identify any potential problem areas. Often, people who undergo a health assessment come out of it reassured that their body is in tip-top condition. Sometimes, it can help people spot a problem, such as high blood pressure or high cholesterol. In some cases, it can even help catch fatal diseases like cancer in their early stages.

A health assessment may include the following elements: a medical history and lifestyle questionnaire, in order to gain a better understanding of your health; a physical examination that assesses the state of your health through a number of tests; and a consultation with a doctor or medical advisor to discuss the results of your assessment. A comprehensive health assessment will also give you the chance to discuss your own concerns and come up with a plan for improving your health with your doctor. Some health assessments may be spread over two days, if test results are not available immediately, while others may be concluded in one day.

Many people undergo a health assessment as an essential requirement of their health cover. However, some choose to take one if they’re worried about a particular aspect of their health. If you fall into the latter camp, don’t simply pick the first hospital you see that provides the service. Remember that health assessments aren’t a one-size-fits-all procedure; they can vary from basic check-ups to detailed investigations in particular areas of your body. Some hospitals offer specialist health assessments for women and for older people, so consider what your health priorities are – and how much you can spend – before opting for a particular service.

Methods of Cardiovascular Health Assessment

In the modern world people constantly experience the influence of many negative factors such as stress, a polluted environment, overpopulation, poor quality industrial food processing, food substitutes and many others, causing health problems. Many diseases develop very slowly not showing any symptoms for a long time. When symptoms begin showing up, the disease may reach a point when it is extremely difficult if not impossible to cure. Therefore proper and systematic health assessment among the population becomes very important regardless to whether or not people have any health problems.

Unfortunately our healthcare system does not utilize the full potential of preventive measures to guard the health of our citizens using existing technologies and methods of conducting regular health assessments. Thus it is very important to show how to use these efficient methods of mass health assessment.

We all know that cardiovascular diseases are number one cause of mortality in many countries of the world. In the U.S.A. alone about 1 million people die every year due to cardiovascular problems. Therefore it is extremely important to focus on using methods of cardiovascular health assessment on a large scale.

The general public, employers, government and healthcare organizations should share responsibility for public health. Timely and adequate cardiovascular health assessments will equally benefit everyone. People will save their lives. Employers will save money by cutting their expenses on health insurance, treatment, and work absenteeism. The governments will cut tax losses. The healthcare organizations will increase the efficiency of their services.

So how can cardiovascular health assessment be organized on a population level? The most effective approach is to organize and regularly carry out mass health screening of the general public. This can be done at the workplace with large number of employees, in government and public organizations, universities and schools, malls, supermarkets, drugstores, sport clubs and health fairs. To conduct such mass health assessments, small healthcare businesses and mobile groups from large medical centers can be involved by being encouraged by a special national healthcare program.

What tools can be utilized to conduct cardiovascular health assessment as a part of health screening program? There is a wide variety of medical equipment and technologies designed for thorough cardiovascular diagnostic routines such as CT and MRI scans, angiography, ultrasound scanners, stress-test systems and many more. As a rule those are quite expensive procedures conducted in specially equipped medical centers. At the same time there are modern technologies designed for cardiovascular health assessment based on simple and non-invasive methods of testing.
For example, Biocom Technologies has developed a portable system for cardiovascular health assessment based on a special method of pulse wave recording and its further deep analysis to evaluate vascular elasticity and heart rate variability (HRV).

The screening process takes into account the patient’s personal information, their answers to a few health questions, their blood pressure reading, and a 5-minute pulse wave reading, recorded by a pulse oximeter.

The computer program produces a detailed analysis of the given information and formulates a conclusion on the state of the patient’s cardiovascular health, including the following data:

1. Patient information
2. Biometric data
3. Blood pressure evaluation
4. Overall health risk evaluation
5. Autonomic balance and tone evaluation
6. Evaluation of peripheral artery elasticity
7. The patient’s biological age, determined from the state of their cardiovascular health
8. Adaptation capabilities of cardiovascular regulatory mechanisms
9. Blood oxygen saturation
10. General conclusions about the patient’s cardiovascular health condition.

The screening process using this program must be provided by a specially trained technician. After the completion of this process, the patient receives a report which can then be forwarded to their physician who can give them a detailed explanation on their test results and their cardiovascular health condition.

After the completion of the screening process, the technician forwards the patient’s test results to the main test result repository located on a secure Internet server. The patient or their physician can then access the repository archive using a security code. From the archive, they may receive test results for review or see the patient’s testing history. It is recommended to conduct this health assessment four times a year in order to be better able to detect subtle changes in the function of the cardiovascular system and properly adjust treatment methods.

In the near future, Biocom Technologies plans to release an inexpensive simplified method of cardiovascular health assessment for home use. This will enable general consumers to perform their health assessment at home and to monitor its dynamics. Furthermore, they may periodically share their test results with their physician to receive qualified advice on how to improve the state of their cardiovascular health.