CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Preventative Medicine — Billing and Reimbursement Guideline

Guideline governing coding, documentation, and reimbursement for preventive medicine visits (new and established patients) for Neighborhood Health Plan of Rhode Island providers; affects claim submission on CMS-1500 and UB-92 and applies across the plan's products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPreventative Medicine — Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change / minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionIf preventive and sick visits are billed the same day, include documentation and supportive diagnosis coding and use modifier 25 or 59 when appropriate.

SourceLink

POLICY UPDATE CHANGES

Format change and minor edits were made on 9/1/2013.

99381-99387, 99391-99397Preventive medicine CPT code ranges for new and established patients

one per dayOnly one preventative visit payable per day

CMS-1500 & UB-92Applicable claim submission forms

25 or 59Modifiers to indicate separately identifiable service

Preventive Visit Coverage and Billing Rules

Preventive visit billing rules

Covered when ALL of the following are met:

Select preventive CPT code based on patient’s age on date of service: 99381-99387 for new patients; 99391-99397 for established patients.

A routine or preventative diagnosis code appropriate for the patient’s age is required on the claim.

Routine preventive visit includes age-appropriate history and exam (e.g., assessment of growth and development, present health status, motor abilities, coordination skills, diet, sleep, and exercise habits).

Laboratory, radiology services, and immunizations are not typically included in preventive medicine codes and may be separately itemized on the claim.

ALL of the following

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPreventative Medicine — Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeFormat change / minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionIf preventive and sick visits are billed the same day, include documentation and supportive diagnosis coding and use modifier 25 or 59 when appropriate.

SourceLink

On This Page

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Documentation and Modifier Use for Same-Day and Separate Services

Documentation Required

Same-day preventive and sick visit documentation

If a preventive exam and a sick visit are billed on the same day, the provider must retain and submit clinical notes to support review for potential separate payment; supportive diagnosis coding is also required on the claim.

Clinical documentation must demonstrate separate, identifiable services.
Supportive diagnosis coding must be submitted on the claim to justify separate payment.

Billing Rule

Modifier use — append modifier 25 or 59

When a separately identifiable service is provided on the same day as a preventive visit, providers must append modifier 25 or modifier 59 to the appropriate service line to indicate a separately identifiable service.

Use modifier 25 or 59 to indicate the separately identifiable service as stated in the guideline.
Ensure modifier is applied on the claim line with the non-preventive service when documentation supports separate payment.

Key Definitions

Preventative visit

DefinitionA routine or preventative visit coded with an age-appropriate preventive diagnosis and CPT code

Included elementsRoutine assessment of growth and development, present health status, motor abilities, coordination skills, diet, sleep, and exercise habits, and age-appropriate history and exam

Excluded itemsLaboratory, radiology services, and immunizations are not typically included and may be separately itemized on the claim

Separate services same day

When separate services occurIf a preventative exam and a sick visit are billed on the same day, documentation must show separate, identifiable services

Documentation requirementNotes are required to review for potential separate payment

Claim coding and modifiersSupportive diagnosis coding is required on the claim; modifiers 25 or 59 should be used to indicate a separately identifiable service

OpenPayer

Preventative Medicine — Billing and Reimbursement Guideline

Preventive Visit Coverage and Billing Rules

Procedure Codes, Frequency, and Claim Submission

Documentation and Modifier Use for Same-Day and Separate Services

Key Definitions