Preventive Medicine and Screening Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans
Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine Service plus 50% of the problem-oriented E/M service code when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.
When a Preventive Medicine Service and Other E/M services are provided during the same visit, only the Preventive Medicine Service will be reimbursed.
Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a papanicolaou smear to the laboratory. These screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine Service rendered on the same day.
Prolonged services are included in (and not separately reimbursed from) preventive medicine codes.
Counseling services are included in (and not separately reimbursed from) preventive medicine codes.
Medical nutrition therapy services are included in (and not separately reimbursed from) preventive medicine codes.
Visual function screening and visual acuity screening are included in (and not separately reimbursed from) Preventive Medicine Services.
For a list of specific codes that are included in (and not separately reimbursed from) Preventive Medicine Services see the Codes Section.
For the purposes of this policy, Same Specialty Physician or Other Health Care Professional is defined as a physician and/or other health care professional of the same group and Same Specialty Physician or Other Health Care Professional reporting the same Federal Tax Identification number.
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Questions and Answers
Q: Why does UnitedHealthcare reduce reimbursement to 50% for an E/M service (99201-99205 or 99212-99215 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine Service?
A: UnitedHealthcare recognizes that a visit may begin as a Preventive Medicine Service, and in the process of the examination it may be determined that a disease related condition exists (E/M). When this occurs, the level of decision-making during such a visit may be more complex than the decision-making during a preventive medicine visit. However, there are elements of the Preventive Medicine Service (e.g., making the appointment, obtaining vital signs, maintaining and stocking the exam room, etc.) that are duplicated in the reimbursement for an E/M code; these duplicated practice expense services are 50% of the E/M cost.
Q: In what situation is CPT code 96110 reimbursable?
A: As defined, CPT code 96110 represents developmental screening, with interpretation and report. In the introduction to the section in which this code appears, the CPT book states that "it is expected that the administration of these tests will generate material that will be formulated into a report." Because a physician obtains developmental information as an intrinsic part of a Preventive Medicine Service for an infant or child and because this information is sometimes obtained in the form of a questionnaire completed by the parents, it is expected that this code will be reported in addition to the preventive medicine visit only if the screening meets the code description. Physicians should report the specific CPT code, for developmental screening or other similar screening or testing, separate and distinct from the Preventive Medicine Service only when the testing or screening results in an interpretation and report by the physician being entered into the medical record.
Questions and Answers
Q: Why is Q0091 not separately reimbursable when billed with a preventive medicine code?
A: UnitedHealthcare considers Q0091 to be an integral part of a preventive health care service. Therefore, this component of a preventive visit is not separately reimbursable.
Q: Why is 99172 not separately reimbursable when billed with a preventive medicine code?
A: The CPT Book clearly states that this service should not be reported in addition to an E/M code.
Q: How does UnitedHealthcare reimburse for screening tests based on a questionnaire completed by the patient or a family member when done in conjunction with a Preventive Medicine Service?
A: Counseling, anticipatory guidance and risk factor reduction interventions are integral to a preventive medicine visit. Historical information may be obtained either through direct questioning or through completion of a written questionnaire. The responses on a questionnaire often identify areas for more focused interventions or treatments. Since this screening is part of a Preventive Medicine Service, it is not reimbursed separately. Occasionally, a screening instrument requires interpretation, scoring, and the development of a report separate from the preventive medicine encounter. In those situations, where a CPT code exists for that service, screening, interpretation and development of a report is reimbursed separately from a Preventive Medicine Service.