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Gain specifics on how to prevent or minimize unnecessary lost revenue.

When billing for a preventive medicine evaluation and management (E/M) service, according to CPT^® guidelines, immunizations/vaccines/toxoid products, immunization administrations, ancillary studies involving laboratory, other procedures, or screening tests (e.g., vision, hearing, developmental) identified with a specific CPT^® code are reported separately.

Sometimes a payer will pay these tests separately, and other times they will it the additional services as bundled, stating the service is part of another service that has already been processed. This is frustrating for coders but can be avoided.

Read further to find out how to get these claims paid.

Follow the Guidelines Exactly

The key to billing preventive medicine E/M and getting ancillary services like vision, hearing, and developmental screenings paid separately lies in understanding the coding rules and properly documenting the services provided.

First and foremost, start with the correct preventive medicine E/M CPT^® code, which is based on the patient’s age, along with the additional CPT^® codes specific to each screening.

Appropriate codes may include:

• 99381-99395 (Initial comprehensive preventive medicine evaluation and management 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, new patient; infant (age younger than 1 year)) - (…, established patient; 18-39 years)
• 99177 (Instrument-based ocular screening, bilateral; with on-site analysis) for spot vision

• 92558 (Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis) for hearing
• 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument), with scoring and documentation, per standardized instrument) for developmental screenings

It is crucial to document each service separately, including the type of screening done and the results.

Navigate NCCI Edits for Smooth Preventive Medicine Billing

Understanding National Correct Coding Initiative (NCCI) edits when coding for preventive medicine and ancillary services is vital to ensure correct coding, avoid denials, maximize reimbursement, and stay compliant with payer guidelines. Most importantly, an understanding of NCCI edits will help maintain a smooth revenue cycle.

NCCI edits are designed to ensure that codes are used appropriately and that services provided during a visit are not being overbilled or bundled incorrectly. When a claim does not adhere to the NCCI edits, payers may deny or reduce reimbursement. NCCI edits specify which services are considered bundled into other services. Knowing these edits helps prevent unbundling errors.

Modifier Magic: Unlocking Approval and Avoiding NCCI Edit Denials

When billing for these ancillary services, use the appropriate modifier (e.g., 25, 59), when required, to indicate that the preventive service and the additional service were performed separately.

We all know that one purpose of the modifier 25 is to indicate that a separately identifiable E/M service was provided on the same day as another service (like a preventive visit or procedure). It tells the insurance carrier that although another service was performed, the E/M service was distinct and met the requirement for reimbursement on its own.

When billing for ancillary services during a preventive medicine E/M visit, modifiers may be required to indicate that the service is separately identifiable.

For example:

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) should be appended to the preventive E/M code when also billing for the administration of vaccines (e.g. 90471-90474 (Immunization administration) and/or 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) and +90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered).
  • Per NCCI edits, 99391 is a component of code(s) 90471-90471 and 90460/90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered)/ (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered)/(… over 18 years of age ….) and modifier 25 is allowed to indicate it is a separate service.
• Modifier 59 (Distinct procedural service) may need to be applied to a code like 99177 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis) when billed with a separate, unrelated E/M service to show it is a distinct procedure.
  • Per NCCI edits, 99177 is a component of code(s) 99202-99215 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) - (… 40 minutes must be met or exceeded), but modifier 59 is allowed to indicate it is a separate service. The use of modifier 59 is appropriate as long as the separately identifiable E/M is not related to a vision issue.

Modifying for Success: Ensuring Payment on Screening Forms

During a preventive medicine E/M, a variety of screening forms are commonly performed to assess the overall health and development of the patient. These screenings are important for identifying potential health issues early, tailored to the patient’s age, developmental stage and health history.

Some of the most common types of screenings forms include Ages and Stages Questionnaire^® (ASQ), billed with code 96110; PHQ-9^® (Patient Health Questionnaire-9) or GAD-7^® (Generalized Anxiety Disorder-7), billed with code 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument); S2BI^® (Screening to Brief Intervention for substance abuse), billed with code 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument); or the EPDS^® (Edinburgh Postnatal Depression Scale), billed with code 96161 (Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument).

Did you know there are several NCCI edits that can impact reimbursement on multiple screenings during the same visit — and that knowing these coding rules and knowing when to append a modifier can make the difference between getting paid and getting a denial?

Below are two common scenarios that require a modifier in order to obtain reimbursement on multiple screening forms at the same visit:

Payer Discretion: When Even the Right Modifier Isn’t Enough

An payer can still deny a service even with an appropriate NCCI modifier added, because the payer may have their own internal coding rules that are stricter that the NCCI guidelines, may not recognize the clinical justification for the modifier used, or may require additional documentation to support the medical necessity of the service beyond just the modifier. The payer ultimately has discretion to review the claim based on their own standards and deny payment if they don’t find the service medically necessary. Be sure to check with each payer’s preventive services billing guidelines to ensure you’re compliant.

Screening Summary in a Nutshell

In summary, understanding coding rules, NCCI edits, and payer-specific guidelines helps to ensure you have a healthy, efficient revenue cycle while simultaneously avoiding the frustration of unnecessary denials.

Donna Walaszek, CCS-P, Northampton Area Pediatrics, Northampton, Massachusetts