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 (99201-9