Preventive Medicine Services

Preventive care visits are coded based on the patient’s age and the services provided, not medical complexity or time. These involve periodic screenings and interventions in order to justify the preventive care code. The timing of pediatric visits is standardized by Bright Futures from the American Academy of Pediatrics; adults should have a yearly wellness visit .  Screening recommendations come from the US Preventive Services Taskforce (USPSTF). We will describe pediatric and adult visits separately and in detail.

You must first determine if the patient is a new or established patient. Remember that a new patient is one who hasn’t been seen by you or another family physician in your medical group in the last 3 years. Then choose the correct CPT code, based on the patient’s age (see table below). Place the corresponding ICD-10 code as the first diagnosis (not medical problems or encounters for vaccines). Please note that there are diagnosis codes for wellness exams with normal or abnormal findings. If new abnormalities are found, you should list the ICD-10 diagnosis codes afterwards. You may also need to place a modifier and routine office visit code if you are actively managing these issues during the visit. However, if the patient has stable chronic problems, this doesn’t count as “abnormal findings.”  

CPT Code		ICD-10 Code
New	Established
99381  Infant Less than 1 year	99391  Infant Less than 1 year	Z00.110 Health supervision for a newborn under 8 days old Z00.111 Health supervision for newborns 8 to 28 days old Z00.121 Routine child health exam with abnormal findings Z00.129 Routine child health exam without abnormal findings
99382  Early childhood Age 1-4   99383  Late childhood Age 5-11   99384 Adolescent Age 12-17	99392  Early childhood Age 1-4   99393 Late childhood Age 5-11   99394 Adolescent Age 12-17	Z00.121 (...with abnormal) or Z00.129 (...without abnormal)   If performed: Z01.411 Encounter for gynecological exam with abnormal findings Z01.419 Encounter for gynecological exam without abnormal findings
99385  Adult Age 18-39   99386 Adult Age 40-64   99387 Adult Age 65 +*	99395  Adult Age 18-39   99396  Adult Age 40-64   99397  Adult Age 65 +*	Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings   If performed: Z01.411 Encounter for gynecological exam with abnormal findings Z01.419 Encounter for gynecological exam without abnormal findings   May also include: Z11.51 Screening for human papillomavirus (HPV) and/or Z12.4 Encounter for screening for malignant neoplasm of cervix
G0402: IPPE “Welcome to Medicare**  or G0438: Initial Annual Wellness Visit**   G0439: Subsequent Annual Wellness Visit** If includes a PAP, add Q0091**   If including a pelvic and breast exam, add: G0101**		Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings
*Only for patients NOT using Medicare
**G codes are for Medicare patients ONLY

 

1.    Pediatric Wellness Visits:

  The American Academy of Pediatrics Bright Futures recommends “well-child” visits at the following intervals: 3 to 5 days, 1-2 weeks, then 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months. Afterwards, each child should have a yearly visit starting at age 3 through 21. The ICD-10 and CPT codes for each age are found in the previous table. During preventive care visits, vital signs are checked, growth is monitored, and the child’s diet, sleeping patterns, social interactions, and safety are reviewed with the caregiver. Depending on the child’s age, there are also developmental screenings, vision and hearing testing, laboratory studies, vaccine administration, and patient counseling.

  In order to justify billing as Preventive Care, documentation should include:

• • Past and Current Medical History, including a prenatal and birth history
  • Review of Dietary, Exercise, Sleep, Toileting habits (as applicable)
  • ]Review of Systems
  • Family History
  • Psychosocial History, including caregiver support, home environment, schooling
  •       Structured Developmental Screening (as applicable)
  • Dental, Vision and Hearing Screening (as applicable)
  • Health Risk Assessments (as applicable)
  • Blood Pressure (3-21 years), Weight, Height, Head Circumference (up to 2 years)
  • Full Physical Exam
  • Immunization status
  • Anticipatory Guidance

Most of these will be part of a template provided by your practice. You can also adapt the Bright Futures templates and materials to fit your EHR.  Structured Developmental Screening can be provided electronically or on paper to parents; the scoring and recommendation must be documented or scanned into the chart. The same is true for any structured Health Risk Assessments. 

Newborns Tips: For the very first outpatient newborn visit, some practices offer a nursing visit for a “weight and color” check at 3-5 days of life. If there are no concerns, the physician doesn’t see the newborn, and the nurse bills a 99211 visit. Note that this is an established care nursing code, because there is no longer a new patient nursing code available. 

If a newborn sees the physician for the first visit, this is often coded as a 99381 (new patient preventive care visit). For subsequent visits, the physician then codes 99391 for an established preventive care visit.  If concerns are identified during any of these visits, the physician can place a modifier and E/M visit code with the diagnosis ICD-10 codes.  However, if the first newborn visit becomes focused exclusively on a specific problem, some physicians will bill this as a new patient office visit (99202-99204) instead of a preventive care visit. Check with your colleagues or office manager for local billing practices in these situations.

Screenings and Counseling

Screening questionnaires must be standardized and involve a verified scoring system and interpretation guidelines. Please note that asking your own questions about the child’s vision, hearing, development, or mental health doesn't “count” as a standardized screening tool. Despite being universally recommended as part of pediatric preventive care, screenings require additional CPT codes. Additional screening tools may require additional ICD-10 codes and modifiers.

i.  Developmental Screening
Developmental screening is typically offered at most preventive care visits from 2 months through 5 years old. It also includes autism screening at 18 and 24 months. Different states or practices may also utilize different screening tools than ones you trained with. 

• •   CD-10 Codes include:
    • Z13.42: Encounter for screening for global developmental delays (milestones)
    • Z13.41: Encounter for autism screening
      
      
  •  96110: Structured developmental screening reviews developmental milestones. Common examples include ASQ (Ages and Stages), SWYC, PEDS and M-CHAT. Note: If you're already billing for developmental screening (96110), this code can’t be used again at the same visit for autism screening; it only counts once per visit.

ii.  Behavioral and Mental Health Screening

Besides developmental disorders, behavioral and mental issues may be suspected during a preventive care visit, such as depression, anxiety, other psychiatric or neuro-cognitive disorders, substance use, high risk activities, and unhealthy lifestyle choices. Obviously you can’t provide universal screening for all possible situations, but you should code and bill for any additional screens that you do perform. These may or may not be reimbursed when done at the time of preventive services, depending on the payer. 

Note: the USPSTF recommends annual screening for depression starting at age 12 (12-18 years ol

• • ICD-10 codes may include:
    •  Z13.31: Encounter for screening for depression
    • Z13.41: Encounter for screening for other mental health/behavioral disorders
    •  Z13.89: Encounter for screening for other disorder
      
      
  • 96127: Brief emotional/behavioral assessment includes ADHD, depression or anxiety screening. It can be offered both to adults and children. Examples include the PHQ-9, Edinburgh Postnatal Depression Score, GAD-7, SCARED, and NICHQ Vanderbilt Assessment Scales. A - 25 modifier is required.
    
    
  • 96160 Patient-focused health risk assessment with scoring and documentation. This includes substance use disorders, trauma or other safety concerns, and eating disorders (e.g., ACES, AUDIT, BSTAD, CAGE, CRAFFT, S2BI, DAST-20, HEEADSSS, Mini Nutritional Assessment).  A 96160 can't be billed during preventive care visits (including Medicare Wellness for adults). Some health insurance only covers 96127, while others only cover 96160: check with your office manager about which code to use. Note: this code doesn’t include time-based interventions for these disorders if the screen is positive.
    
    
  •  96161 Caregiver-focused health risk assessment instrument (e.g., Edinburgh Postnatal Depression Inventory, Caregiver Strain Index) for the benefit of the patient, with scoring and documentation. This can be done at 1, 2, 4 and 6 months. The scoring should be documented in the child’s chart. If the caregiver is also your patient, you should have the results documented in both charts and you can bill both if you also see the caregiver that day as a patient. While this code is generally used in pediatric care, an adult patient who is dependent on caregivers may benefit from caregiver-focused screening.

Counseling and Brief Interventions

During a preventive care visit, general counseling on healthy lifestyles and risk avoidance is expected. Addressing specific issues is going “above and beyond” a typical wellness visit.  The counseling interventions for substance use (nicotine, alcohol, substances) are typically based on time. The ICD-10 and CPT codes for counseling on substance disorders are covered in the Adult Preventive Care section, but the codes are the same as used in pediatric care.

iii. Vision and Hearing Screening

Vision screening should be performed at ages 4-7 years and then every other year through age 12, and again at age 15. There are a few other vision screening CPT codes, such as when specialized ocular machine testing is used. If you are expected to enter these codes, ask your office manager which codes your office uses.

• • 99173: Routine vision screening delivers a quantitative estimate of visual acuity and is typically done with a Snellen chart.

Routine hearing screening is performed annually at ages 4-6 years, then at ages 8 and 10, and by audiometry with high frequencies once each, between ages 11-14, 15-17, and 18-21. Note: these CPT codes are not the same as newborn hospital hearing screening (92586).

• • 92551 Screening test, pure tone, air only
  • 92583 Select picture audiometry
  • 92567 Tympanometry (impedance testing)
    

 iv.    Pediatric Laboratory Screening

There are only a few routine preventive pediatric laboratory screens, namely Hgb, Lead, and Lipid panel (per AAP Guidelines). For reimbursement, no specific ICD-10 codes are needed for these labs outside of the well-child ICD-10 codes.

Note: When you order screening labs, there are separate venipuncture collection CPT codes (for drawing the blood) and CPT codes for the analysis of the specimen (which the lab charges).  Your lab order typically includes the latter but, if the wrong code is accidentally entered, the lab will either change it or contact you to clarify the correct order. 

If your office both collects the specimen and analyzes it “in house,” your lab should charge for both. If the specimens are collected in-house but sent to another facility for analysis, your lab will place the CPT codes for the collection and the outside lab will charge health insurance for the analysis.

v.  Fluoride administration

Prophylactic fluoride administration begins with teeth eruption and should be applied every 6 months (either in office or at the dentist) for low risk children through age 5. For high risk children, it may be done as often as 4 times a year but may only be billed twice a year.

• • Z29.3: Encounter for prophylactic fluoride administration
  • 99188 Fluoride application

vi.  Vaccine Administration

   There are several types of CPT codes for vaccines. There are two counseling codes used by the physician, depending on how many vaccines are discussed. There are also two administration codes used by the nursing staff, which depend on the number and route of the administration. 

Note: In most cases, physicians don’t bill for vaccine counseling unless significant vaccine-related counseling is given. Instead, nurses or other staff will enter the appropriate nursing administration codes and specific vaccine codes. Because there are many vaccines and combinations of vaccines, we don’t include those codes here, but they can be found online and are typically built into your EHR ordering system.

• • Z23: Encounter for Immunization—may also include:
    • Z28.3: Under-immunized status (include the reason)Z28.82: Caregiver refusal of vaccine (see other reasons in the Z28.8 series)
    • Z71.85: Encounter for immunization safety counseling
  • 90460 if physician performs face-to-face counseling with the caregiver up to age 18, for first vaccine; and
  •  99461 for each subsequent vaccine counseling
  • 90471 nurse administration of injectable vaccine for the first vaccine; and
  • 90472 for each subsequent injection
  • 90473 nurse administration of intranasal or oral vaccine for the first vaccine; and 90474 for subsequent intranasal or oral vaccine
  • CPT code(s) of the specific vaccine or vaccine combination are billed.

Daycare Form

Some early childcare facilities require completion of well-child forms. Physicians and/or staff can usually fill these out based on the most recent preventive care visit, but this does involve unpaid time. In some cases, a routine preventive care visit is “past-due” and needed in order to complete the form. If a visit is scheduled to complete the form, but a comprehensive preventive care visit is not indicated, a routine office visit should be charged while addressing any pertinent concerns.

Pre-Participation Sports Physicals

This will be covered in detail later in this chapter. Note that these visits aren’t billed as preventive care services. You can perform a pre-participation sports physical at the same time as a preventive care (well child) visit, but it is usually billed separately.

Examples. Let’s try a few examples:

Example 1: A 12-month-old child presents for a routine pediatric wellness exam. The child has seen you for all other routine care. The mother says the child has recovered from a minor URI and only wants reassurance that there is no ear infection. You don't note any concerns on exam or routine screenings. You find a few teeth eruptions and administer fluoride. Nursing staff administer routine vaccinations and you order screening Hgb and Lead levels.  

→ Billing Level: Pediatric wellness exam, 12 month; Established patient

• • • • Z00.129 (...without abnormal); Z13.42 Encounter for screening for global developmental delays  
        (milestones); Z23 Encounter for Immunization.
      • CPT: 99392 (1-4 years, established); Developmental Screening: 96110; Fluoride varnish: 99188.
      • Nursing staff should enter: Nursing administration of routine vaccines: 90471 and 90472 for additional vaccines; Specific codes for vaccines.
      • Hgb and Lead will have CPT codes attached when you order them.

Example 2: An 18-month-old child presents for a “daycare form.” The child has seen you at 9 months for routine care but is behind on visits and vaccines. You explain that a preventive care visit is needed. You screen the child for developmental delay and note mild delays for which you provide some guidance and community resources. Autism screening was normal. No other concerns noted. You administer fluoride and nurses provide vaccines. You order lead and hgb levels since the child is behind. You fill out the daycare form, for which you don’t typically bill. 

→ Billing Level:

• • • • Pediatric wellness exam, 18 month; Established patient.
      • ICD10: Z00.121 (...with abnormal); Z13.42 Encounter for screening for global developmental delays (milestones); Z13.41 Encounter for autism screening; Z23 Encounter for Immunization; R62.0 Delayed Milestone.
      • CPT: 99392 (1-4 years, established); Developmental Screening: 96110; Fluoride varnish: 99188.
      • Nursing staff should enter: Nursing administration of routine vaccines: 90471 and 90472 for additional vaccines; Specific codes for vaccines.
      •  Hgb and Lead will have CPT codes attached when you order them.

Example 3: A 2-month-old child presents for an initial visit and hasn’t been seen since discharge from the hospital. The mother is tearful stating she is overwhelmed and “just forgot.” You screen the child for developmental delay and also screen the mother for depression, which is positive, so you schedule her for a visit as well. No other concerns are noted. Nurses provide vaccines. 

            → Billing Level:

• • • •        Pediatric wellness exam, 2 months; New patient.
      •        ICD10: Z00.129 (...without abnormal); Z13.42 Encounter for screening for global developmental delays (milestones); Z23 Encounter for Immunization; You may include Z28.3 Under-immunization status.
      •        CPT: 99381 (Under 1 year, new); Developmental Screening: 96110; Caregiver Assessment: 96161.
      •        Nursing staff should enter: Nursing administration of routine vaccines: 90471 and 90472 for additional vaccines; Specific codes for vaccines. 

Example 4: A 6-year-old child presents for an established preventive visit. The child has mild intermittent asthma and the mother requests refills of albuterol and a new spacer. There are also some new significant patches of eczema causing excoriations. You perform vision and hearing screening, since these haven't been done in the last two years. You then discuss that addressing additional problems and prescribing medications aren’t part of a preventive care visit and an additional visit code would be charged as a separate visit, to which the mother agrees. You review the Asthma Action Plan, print another copy, provide albuterol and some instruction about spacers. You prescribe a moderate dose steroid and provide careful instructions on its use. Nurses provide vaccines. 

          → Billing Level:

• • • •        Pediatric wellness exam, 6-year-old; Established.
      •       ICD10: Z00.121 (...with abnormal); Z23 Encounter for Immunization; J45.2 Mild Intermittent Asthma; L20.9 Atopic Dermatitis. 
      •        CPT: 99393 (5-11 years well child check); CPT 99173 (Vision screening) and CPT 92551 (hearing screening if machine only changes frequency tones and doesn’t change intensity [threshold]).
      •       CPT: Also -25 modifier with 99214 (Moderate Diagnosis: 1 chronic problem, stable, 1 acute new problem; Moderate Risk with 1 refill and 1 new prescription).
      •        Nursing staff should enter: Nursing administration of routine vaccines: 90471 and 90472 for additional vaccines; Specific codes for vaccines. 

Example 5: Two fraternal twins present for their first weight and color visit after you saw them in the hospital. For Twin A, the nurse notes some issues with the umbilical cord and a “rash.” You find a normal umbilical cord, actively detaching, and erythema toxicum, for which you provide reassurance. There are no concerns with Newborn twin B so you only examine Twin A.  

          → Billing Level: Both are new patients

• • • • Twin A
        • Option one: Routine office visit, 99203 (2 self-limited minor problems, low risk); P83.1 Neonatal Erythema Toxicum.
        •  Option two: 99381 (New infant less than 1 year); Z00.110 Health supervision for a newborn under 8 days old; P83.1 Neonatal Erythema Toxicum.
      • Twin B:
        •        Nursing Visit: 99211 (Even though this isn’t a new patient, there is no new patient nursing visit, so it’s billed as an established nursing visit).
        •        If you had seen this patient, you should bill 99381 and Z00.110
          

b. Adult Preventive Care Services

Adults should have a preventive care visit every year. In general, you will use the United States Preventive Services Task Force (USPSTF) recommendations, which include monitoring of blood pressure, weight, laboratory studies, vaccine administration, cancer screening, mental health and substance use screening, and counseling. Most health insurance payers will cover an annual visit along with Grade A and B recommendations at no cost to the patient.

Review the table above for adult preventive care codes. For appropriate populations, you will also include the ICD-10 code for an encounter for a gynecological exam, with or without abnormal findings. If you are only performing gynecological screening without a full adult preventive care visit, then only use the ICD-10 code for the gynecological exam and not Z00.00 or Z00.01 (Annual adult preventative exam, without or with abnormalities, respectively). 

i.   Laboratory and Radiology and Other Screening:

Most Grade A and B recommended laboratory studies are listed below. In order to indicate that a particular test is for screening purposes (rather than due to an established diagnosis or symptom), you should try to include the screening ICD-10 codes below. Remember that most “Z” codes are for screening. If additional laboratory tests are ordered outside of Grade A and B recommendations, these may not be covered, even if you enter a screening ICD-10 code. For example, screening for hypothyroidism, anemia, diabetes, kidney or liver disease, and vitamin deficiencies are not part of USPSTF recommendations, so ordering a yearly CMP, CBC, TSH or Vitamin D purely for “screening” may result in out-of-pocket costs to the patient. If there are specific symptoms prompting testing, you may use diagnostic ICD-10 codes. 

Below are some common ICD-10 screening codes that you will use for screening:

• • Cervical cancer screening
    •        Z01.411 Encounter for gynecological examination with abnormal findings*
    •        Z01.419 Encounter for gynecological examination without abnormal findings 
    • If performed:
      •  Z12.4 Encounter for screening for malignant neoplasm of cervix
      • Z12.72 Encounter for screening for malignant neoplasm of vagina (e.g., for those without a cervix)

*If abnormal findings are discovered on screening examination (e.g., vaginal discharge, cervical polyp, labial lesion), include additional ICD-10 diagnostic codes.

• • Breast cancer screening
    •        Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
    •        For screening mammogram, with additional concerns, use Z12.31 along with the reason, such as:
    •        Z79.82 Breast Implants
    •        Z85.3 History of Breast Cancer
    •        Z80 Family History of Breast Cancer
    •        Note: For diagnostic evaluation, you must include the symptom or exam finding ICD-10 code prompting a diagnostic mammogram (since it’s not for screening), such as:
    •        R92.8 Abnormal Mammogram
    •        N63.1 - N63.42 Breast lump (with description)
    •       N64.51 Induration of Breast
    •       N64.52 Nipple Discharge
    •       N64.53 Retraction of Nipple 
    •        N64.59 Other Breast Symptoms
    •        N64.4 Mastodynia
    •        Z87.2 History of Dimpling
    • N62.0 Gynecomast
  • HIV screening
    •  Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
    • If high-risk sexual activity, HIV screening can be ordered with: Z72.5 High risk sexual behavior
  • Hep B and C screening
    • Z11.59 Encounter for screening for other viral diseases
  • Other STIs (blood-borne or genital)
    • Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission
    • Z72.5 High risk sexual behavior
      
  • Tuberculosis screening (some payers only cover testing after exposure/symptoms)
    •  Z11.1 Encounter for screening for respiratory tuberculosis
  • Osteoporosis screening (some payers require menopausal status)
    • Z13.820 Encounter for screening for osteoporosis
    • Z78.0 Asymptomatic menopausal state
  • Prostate cancer screening
    • Z12.5 Encounter for screening for malignant neoplasm of prostate
  • Aortic aneurysm screening
    • Z13.6 Encounter for screening for cardiovascular disorders
  • Lung cancer screening
    • Z12.2 Encounter for screening for malignant neoplasm of respiratory organs
  • Colon cancer screening
    • Z12.11 Encounter for screening for malignant neoplasm of colon
  • Dyslipidemia screening
    • Z13.220 Encounter for screening for lipoid disorders

ii. Vaccine Administration 

The ICD-10 codes for vaccination are the same as for pediatrics. To review:

• • • • Z23 Encounter for Immunization  

There are no physician counseling codes for vaccination for adult patients. 

As discussed previously, vaccine administration CPT codes are generally placed by the nurse or other staff who administer the vaccines. These codes are determined by the number and route of vaccine administration, however the vaccines themselves have codes. 

• • • • 90471 Administration by injection only, no counseling; one vaccine/toxoid or combination vaccine
      •  90472 Administration by injection only, no counseling; each additional
      • 90473 Immunization only, no counseling, by intranasal or oral route; one vaccine/toxoid or combination vaccine
      • 90474 Immunization only, no counseling, by intranasal or oral route; each additional

Note: Medicare Part B covers the seasonal influenza vaccine annually and has its own code: G0008 Administration of influenza virus vaccine 

• • • •        CPT code of the specific vaccine or combination is billed
        
        

iii.  Behavioral or Mental Health Screenings and Brief Interventions

There are a number of standardized screening tools for behavioral or mental health concerns, substance use disorders and high-risk activities. For those who screen positive, there are also physician-based counseling codes with brief interventions called SBIRT: Screening, Brief Interventions and Referral to Treatment. Screenings and brief interventions can be performed during both preventive care visits and routine office visits.

Screenings should be billed for reimbursement of the time and costs of administering the screen, and scoring and documenting the results, even if the screen is negative. However, during routine office visits, if the visit itself is centered around the screening and intervention, it is considered part of that visit and additional CPT codes aren’t used. If the screening and/or intervention is in addition to the routine office visit, then a modifier and additional CPT codes can be billed. If a brief intervention is provided, the screening is then typically considered part of the time-based counseling CPT code. It is important to document the time spent on the intervention in your note.

For example, if a patient schedules an office visit to address smoking cessation strategies and you spend the visit discussing strategies, this would be coded as a routine office visit; no additional screening or intervention codes would be billed (to prevent double-dipping). However, if a patient is seen for other acute or chronic care issues, and you spend an additional 3-10 minutes counseling on smoking cessation, then the additional CPT code (99406) can be added, after placing a -25 modifier to the routine office visit code (time spent counseling needs to be documented).

Here are some common ICD-10 and CPT screening codes for adults:

• • • Z13* Encounter for screening examination for mental health and behavioral disorders
      • Z13.31 Encounter for screening for depression
      • Z13.32 Encounter for screening for maternal depression
      • Z13.39 Encounter for screening for other mental health and behavioral disorders
      • Z13.89: Encounter for screening for other disorder
        
        
    • 96127 Brief emotional and behavioral assessment with scoring and documentation. This includes screening tools for depression (e.g., PHQ-9, Edinburgh Postnatal Depression Score), anxiety (GAD-7), and ADHD (e.g., NICHQ Vanderbilt Assessment Scales).
      
      
    •  96160 Patient-focused health risk assessment with scoring and documentation. This includes substance use disorders, trauma or other safety concerns, and eating disorders (e.g., ACES, AUDIT, BSTAD, CAGE, CRAFFT, S2BI, DAST-20, HEEADSSS, Mini Nutritional Assessment). A 96160 typically can't be billed during preventive care visits (including Medicare Wellness for adults). Some health insurances only pay for 96127, while others only cover 96160, so check with your office manager about which code to use.
      
      
    • Note: This code doesn’t include time-based interventions for these disorders if the screen is positive.
      •  If billing an office visit based on time, be sure to delineate the time spent and what was addressed (to demonstrate you aren’t double-dipping, are billing based on time for other items, and not overlapping with the above assessment codes).
        
        

SBIRT Codes for Alcohol or Other Substance Use:

• • • F10-F19 (series): specify the substance(s) and other factors
      
      
    • 99408 Alcohol or substance (other than tobacco) abuse structured screening (e.g., Alcohol Use Disorder Identification Test [AUDIT], Drug Abuse Screening Test [DAST]) and brief intervention (SBI) services for 15 to 30 minutes and 99409 for > 30 minutes
      
      
    • Medicare
      • G0396: Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes
      • G0397: Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

SBIRT Codes for Nicotine Dependence: 

• • • F17 (series) Nicotine Dependence: specify the mode of delivery (cigarettes, chewing, vaping, etc.) and whether uncomplicated, in withdrawal, in remission, etc. 
    • 99406 Smoking and tobacco use cessation counseling 3-10 minutes, and
    • 99407 for > 10 minutes. You need to list the amount of time spent on counseling and briefly note what was discussed. A -25 modifier is needed.

iv. Other Screening or Counseling Codes

There are other screening or counseling interventions which we can't cover in detail, but here are a few more commonly used codes:

Family Planning Counseling:

In general, routine family planning counseling and interventions are considered part of a preventive care visit and no additional CPT codes are included unless a procedure is performed. If extensive time is spent on counseling about family planning, physicians will typically use routine office visit codes. Women’s health codes for procedural contraceptives are covered later on.

• • • Z31.61 Procreative counseling/advice using natural family planning
    • Z31.69 Preconception care and other procreative management
    • Z30.01 Encounter for initial prescription of contraceptives
    • Z30.9 Encounter for contraceptive management, unspecified
    • Advance Care Planning:
      Advance Care Planning conversations can provide significant reimbursement for a lengthy and important conversation. This code can be billed multiple times per month, both in the hospital and in the outpatient setting. No specific forms need to be completed by the end of the visit, but your time and the nature of the discussion should be documented. For example, “I provided additional advance care planning services with the patient and family for 16 minutes, including a detailed discussion about DNR.”  You must counsel them for at least 16 minutes on the day of service to bill this service (to bill the first 30-minute increment). If you spend additional time, you may then bill additionally for each 30-minute increment.
      
      You may use the ICD-10 code for the medical condition prompting the Advance Care Planning discussion, or a routine wellness or preventive care code, or Z71.89 Other specified counseling on factors influencing health status and contact with health services.

If this is a Medicare visit, you should bill for advance care planning with a -33 modifier with the preventive visit code, followed by the following codes. If not, no modifier is needed.

• • • •        99497: first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate and,
      •        99498: each additional 30 minutes thereafter

 Examples. Let’s try a few examples:

Example 1: A 35-year-old established female patient presents for a routine wellness exam. Her PHQ-9 was negative and there are no concerns on exam. You obtain a PAP smear and she requests testing for STI with swabs, but HIV, Syphilis, and Hep C were already performed. You provide TDaP and influenza vaccinations. Finally, she says she would like to conceive soon and asks about stopping contraceptives; you briefly discuss this option, and address a few questions about preconception health and fertility. 

→ Billing Level:

• • • •  ICD-10: Z00.00 (Adult, without abnormal); Z01.419 (Gyn exam, without abnormal); Z12.4 (Screening for cervical cancer); Z11.3 (Screening for STIs); Z13.31 (Screening for depression); Z31.69 (Preconception care and other procreative management).
      • CPT: 99395 (Age 18-39, established); 96127 (PHQ9).
      • Nursing staff should enter: Nursing administration of routine vaccines: 90471, and 90472 for additional vaccines; Specific codes for vaccines

Example 2: A 50-year-old established patient presents for a preventive visit but also would like you to refill flonase, prescribe an antihistamine for chronic allergic rhinitis due to pollen, as well as to freeze three lesions. You inform him that in order to assess his medications, you need to charge him additionally for a routine office visit, and you have time to freeze the seborrheic keratosis. You perform all recommended screenings, including PHQ-9, and order a colonoscopy. No new problems are noted.

→ Billing Level:

• • • •        ICD-10: Z00.00 (adult, without abnormal); Z13.31 (Screening for depression); Z12.11 (Encounter for screening for malignant neoplasm of the colon); J30.1 (Allergic Rhinitis due to Pollen); L82.1 (Seborrheic keratosis).
      •        CPT: 99396 (40-64, established), -25 modifier, 99214, 96127, 17000 (Cryotherapy for first lesion), 17003 (for additional lesions up to 14). 

Example 3: A 45-year-old new patient presents for a “well woman exam” but says she sees her regular doctor for all routine preventive and chronic health. Her PCP is at a different practice and has already ordered a mammogram during her annual wellness exam last month. She states she doesn't want her PCP “looking down there” because she works in his office. You perform a pelvic exam with PAP, but don’t perform any other screening. She has an IUD but would like it checked because she can’t feel the strings. You note the IUD strings, but also note vaginal discharge and perform swabs.

→ Billing Level:

• • • •        ICD-10: Z01.411 (Gyn exam, with abnormal); Z12.4 (Screening for cervical cancer); Z30.431 (Contraceptive check); N89.8 (Vaginal discharge).
      • CPT: 99203
      • Note that while this is reported to be a “well woman” and while you did do a pelvic exam with a PAP, you didn’t perform all routine screening. You can’t bill for an annual wellness exam, since the PCP already performed an annual wellness. 

Example 4: A 34-year-old established patient presents for an annual wellness visit and doesn’t need a gynecologic exam or labs at this visit. You perform all the necessary screening, including for depression.  You also discuss smoking cessation strategies for 5 minutes. 

→ Billing Level:

• • • • ICD-10: Z00.00 (adult, without abnormal); Z13.31 (Encounter for screening for depression); F17.210 (Nicotine dependence, cigarettes, uncontrolled);
      • CPT: 99395 (Age 18-39, established) and -25 modifier; 96127 (PHQ9), 99406 (Smoking cessation)

c. Social Determinants of Health and Adverse Childhood Events
Increasingly, Social Determinants of Health are being included in medical complexity risk factors and for hospital reimbursement. Although not live at the time of this writing, G0136 should be billed in the outpatient setting and is planned to be covered by Medicare beginning July 1, 2024 for administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, and not billed more than every 6 months.

Some Adverse Childhood Events (ACEs) are also codable and may be helpful to include for interventions and follow-up. The Z55-75 series has the most common SDOH and ACE codes and are listed below:

 

ICD-10 Code Category	Problems or Risk Factors
Z55  Problems related to education and literacy	Z55.0 Illiteracy and low-level literacy Z55.1 Schooling unavailable and unattainable Z55.2 Failed school examinations Z55.3 Underachievement in school Z55.4 Educational maladjustment and discord with teachers and classmates Z55.8 Other problems related to education and literacy
Z56  Problems related to employment and unemployment	Z56.0 Unemployment, unspecified Z56.1 Change of job Z56.2 Threat of job loss Z56.4 Discord with boss and workmates Z56.5 Uncongenial work environment Z56.6 Other physical and mental strain related to work Z56.89 Other problems related to employment
Z57  Occupational exposure to risk factors	Z57.0 Occupational exposure to noise Z57.2 Occupational exposure to dust Z57.31 Occupational exposure to environmental tobacco smoke Z57.39 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.5 Occupational exposure to toxic agents in other industries Z57.8 Occupational exposure to other risk factors
Z59  Problems related to housing and economic circumstances	Z59.0 Homelessness* Z59.1 Inadequate housing* Z59.2 Discord with neighbors, lodgers and landlord Z59.3 Problems related to living in residential institutions* Z59.4 Lack of adequate food and safe drinking water* Z59.5 Extreme poverty* Z59.6 Low income* Z59.7 Insufficient social insurance or welfare support* Z59.8 Other problems related to housing and economic circumstances*
Z60  Problems related to social environment	Z60.0 Problems of adjustment to life-cycle transitions* Z60.2 Problems related to living alone Z60.3 Acculturation difficulty* Z60.4 Social exclusion and rejection* Z60.5 Target of (perceived) adverse discrimination and persecution* Z60.8 Other problems related to social environment*
Z62 Problems related to upbringing	Z62.0 Inadequate parental supervision and control* Z62.1 Parental overprotection* Z62.2 Upbringing away from parents* Z62.21 Child in welfare custody* Z62.22 Institutional upbringing* Z62.3 Hostility towards and scapegoating of child* Z62.6 Inappropriate (excessive) parental pressure* Z62.810 Personal history of physical and sexual abuse in childhood* Z62.811 Personal history of psychological abuse in childhood* Z62.812 Personal history of neglect in childhood* Z62.819 Personal history of unspecified abuse in childhood* Z62.82 Parent-child conflict* Z62.822 Parent-foster child conflict* Z62.891 Sibling rivalry* Z62.898 Other specified problems related to upbringing*
Z63 Other problems related to primary support group, including family circumstances	Z63.0 Problems in relationship with spouse or partner Z63.3 Absence of family member* Z63.4 Disappearance and death of family member* Z63.5 Disruption of family by separation and divorce* Z63.6 Dependent relative needing care at home* Z63.7 Other stressful life events affecting family* Z63.72 Alcoholism and drug addiction in family* Z63.8 Other specified problems related to primary support group*
Z64 Problems related to certain psychosocial circumstances	Z64.0 Problems related to unwanted pregnancy Z64.1 Problems related to multiparity Z64.4 Discord with counselors
Z65 Problems related to other psychosocial circumstances	Z65.0 Conviction in civil and criminal proceedings without imprisonment Z65.1 Imprisonment and other incarceration Z65.2 Problems related to release from prison Z65.3 Problems related to other legal circumstances Z65.4 Victim of crime and terrorism* Z65.5 Exposure to disaster, war and other hostilities* Z65.8 Other specified problems related to psychosocial circumstances*
Z75 Problems related to medical facilities/ other health care	Z75.0 Medical services not available in home Z75.3 Unavailability and inaccessibility of health care facilities Z75.4 Unavailability and inaccessibility of other helping agencies

*Indicates possible ACE

d.  Medicare Preventive Services
Medicare patients (>65 years old) have unique preventive care services. Traditionally, Medicare covered inpatient care, and acute and chronic disease management. However, as part of the 2003 Medicare Modernization Act, Medicare expanded its benefits to cover preventive care visits. The goal is to reduce hospitalizations and complications by maintaining preventive care recommendations. Medicare uses many of the CPT codes, but it also has its own billing codes that begin with the letter “G.” If you provide multiple services to a Medicare patient, you may end up with a combination of G codes and traditional CPT codes within the same encounter. 

Note: these G codes don't apply to Medicaid patients, only to Medicare patients. 

Medicare Wellness covers a lot of important health information, but requirements vary from other adult wellness exams. Most notably, besides the initial “Welcome to Medicare visit,” these visits lack a physical exam requirement, which can be disconcerting for patients.  Medicare has seven required components and it is possible to be denied reimbursement due to incomplete documentation of all key components: 

1.     Review medical and social history with attention to modifiable risk factors.

2.     Review potential risk factors for depression.

3.     Review functional ability and level of safety.

4.     Height, weight, blood pressure, visual acuity and BMI.

5.     Conduct end-of-life planning.

6.     Education, counseling and referral based on the results of findings of the above 5 services.

7.     Education and a brief written plan such as a checklist for ongoing screening and prevention. 
 

There are useful online templates to fulfill all 7 components and recommendations. Each Medicare wellness visit should include the “after-visit summary” with patient education and a written Personalized Preventive Plan of Service (PPPS). Medicare requires that the patient receive a summary of the visit and outline of any future recommended services. Establishing a good clinic workflow includes establishing pre-visit patient questionnaires, nursing intake forms, and after-visit summaries for the patients. This careful planning will make these visits much less labor intensive and significantly increase productivity. 

There are three possible codes for Medicare Wellness visits:

i.   “Welcome to Medicare,” aka, Initial Preventive Physical Examination (IPPE)

G0402: This is only billed once in a patient’s lifetime and must be done within the first 12 months of enrolling in Medicare (Part B), typically age 65. 

Note: this visit requires a visual acuity screen and is the only visit that covers a screening EKG when deemed to be indicated.

ii.  Annual Wellness Visit (AWV) 

a.     Initial AWV - G0438:  This is also only billed once in a patient's lifetime, but occurs after the first 12 months after enrollment. 

b.     Subsequent AWV - G0439: This applies for all subsequent AWVs after the first AWV.

  

Medicare Covered Service	Timing
G0402 Welcome to Medicare	Once; Within the first 12 months after enrolling Medicare
G0438 Annual Wellness Visit, Initial	Once; After the first 12-month period after enrolling
G0439 Annual Wellness Visit, Subsequent	Annually; After the initial wellness visit (G0438)

Because Medicare Wellness visits are unique, it’s especially important to educate patients about what’s involved in this visit compared to a routine office visit. Patients may be disappointed about not getting a physical exam and/or may wish to address acute or chronic problems. Be transparent about the 7 required elements for the visit and notify them that you will likely not have time to address other issues, which may also result in a copay and/or additional cost to the patient.  Document if you do convert the visit to a regular office visit or do this in addition to the AWV (which can be labor intensive and time consuming). Setting a clear understanding of the agenda with the patient can greatly improve patient and provider satisfaction in this situation.
 

iii. Additional Medicare Screening and Counseling Codes

Additional covered services:

The USPSTF Grade A and B Recommendations are covered by Medicare, but also use Medicare G codes rather than CPT codes. For example, Hepatitis C screening:

• • • G0472: Hepatitis C antibody screening, for individual at high risk and other covered indication(s) (Medicare only)

Women’s preventive services are covered once every 24 months, unless the woman is at high risk, in which case screening can be offered every 12 months. Where appropriate, use Medicare-only billing codes: Q0091 (Screening pap smear) and G0101 (Screening pelvic exam and breast exam). These screenings can be done at a separate visit or in addition to an AWV. A screening EKG for asymptomatic patients isn’t part of the USPSTF Recommendations, but is covered only one-time in the “Welcome to Medicare” visit, coded as G0403.  Providers must determine if it’s indicated.

The only vaccinations covered by Medicare as preventive care are Hepatitis B, Influenza, and Pneumococcal vaccines (13, 23, and 20-valent pneumococcal vaccines). Other routine vaccines, such as tetanus and zoster (shingles), are covered by Medicare Part D or other prescription drug coverage, if the patient has this. It’s best for the patient to price these in pharmacies if they lack Part D.  An exception is that TDaP is covered after an injury under Medicare Part B, but must have an appropriate ICD-10 diagnosis code (e.g., laceration, dog bite) attached to the vaccine administration.

Counseling

For most of the counseling codes below, it’s easier to have them on a list of charges and generate a smart phrase/note template for each code, so that it can be easily pulled into your A/P section of the clinic note (see examples below). Remember that Medicare primarily uses G codes for its services, with the exceptions of Advance Care Planning and Tobacco Use Counseling. Additional resources for incorporating Medicare AWV into your office practice can be found in AAFP’s Family Practice Management’s topic module. 

Counseling codes (Supported by Medicare)	Documentation Needed	Time Required (If needed)
G0101 Medicare Screening Breast and Pelvic Exam	Documentation MUST show at least 7 of the following: 1.  Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge. 2.  Digital rectal examination including sphincter tone and presence of hemorrhoids or rectal masses. 3.  Examination of external genitalia (general appearance, hair distribution or lesions). 4.  Examination of urethral meatus (size, location, lesions or prolapse). 5.  Examination of urethra (masses, tenderness or scarring). 6.  Examination of bladder (fullness, masses or tenderness). 7.  Examination of vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele or rectocele). 8.  Examination of cervix (general appearance, lesions or discharge). 9.  Examination of uterus (size, contour, position, mobility, tenderness, consistency, descent, or support). 10. Examination of adnexa/parametria (masses, tenderness, organomegaly, or nodularity). 11. Examination of anus and perineum.	N/A
Q0091 Medicare Pap Smear Collection	Per physical exam documentation	N/A
G0476 Medicare HPV Testing for Cervical Cancer Screening	Per physical exam documentation	N/A
G0102 Medicare Prostate Cancer Screening: Digital Rectal Exam (DRE)	Per physical exam documentation	N/A
G0444 Medicare Annual Depression Screening	“The patient was screened for depression with a PHQ-9. I spent XX minutes discussing the diagnosis of a mood disorder along with treatment options, referral for psychotherapy, and a plan for follow-up.”	>5 min
99497 Medicare Advance Care Planning	Physician: “Patient voluntarily consented to and received counseling for advance care planning/counseling for living will for XX minutes. Information regarding DPOA for health care, code status, and artificial feeding was provided. Pertinent documents, if signed, are scanned into the EHR.” Care Team: “Patient voluntarily consented to and received counseling for advance care planning/counseling for living will. This service was provided by an additional member of the care team. Please see their separate clinical documentation.”	>16 min
G0443 Medicare Annual Alcohol Misuse Counseling	“A validated screening tool was used and the patient scored positive for alcohol misuses. I spent XX minutes discussing the risks of alcohol misuse and the benefits of decreasing alcohol consumption. I provided counseling, education and recommendations including referrals to outpatient agencies and  for inpatient treatment, discussion of medication options, recommendation/referral for psychotherapy, other: _____.”	>5 min
G0446 Medicare Annual Behavioral Counseling for Cardiovascular Disease	“I spent XX minutes providing behavioral counseling to the patient including assessing their behavioral health risks for CVD based on blood pressure, lipid levels, age, and other risk factors. I provided behavior change advice about the benefits of a healthy diet. I discussed the risks and benefits of aspirin use for primary prevention of CVD, based on age appropriate guidelines (men 45–79; women 55–79). I took into account the patient’s interest and willingness to change their behavior to collaboratively set appropriate treatment goals. I utilized behavior change techniques to assist the patient in achieving the set goals. A plan was discussed for ongoing assistance and support.”	>15 min
G0447 Medicare Behavioral Counseling for Obesity	“I spent XX minutes providing behavioral counseling to the patient, including assessing their behavioral health risks for obesity and factors affecting the choice of behavioral change methods. I provided behavior change advice about the harms of obesity and the benefits of decreased caloric intake and increased physical activity. I took into account the patient’s interest and willingness to change their behavior and, collaboratively, set appropriate treatment goals. I utilized behavior change techniques to assist the patient in achieving the set goals. A plan was discussed for ongoing assistance and support.”  BMI >30 is required.	>15 min
G0445 Medicare Behavioral Counseling to Prevent STIs	“The patient was provided with XX minutes of intensive behavioral counseling regarding STI prevention and methods to decrease high risk sexual behaviors.”	>20 min
99406 Tobacco Use Counseling	“I provided XX minutes of counseling regarding the risk of tobacco use and techniques for smoking cessation.”	3-10 min
99407 Tobacco Use Counseling	“I provided XX minutes of counseling regarding the risk of tobacco use and techniques for smoking cessation.”	>10 min

Note: As previously discussed, Advance Care Planning counseling may occur with the patient, a family member, or a surrogate and, if needed, may occur multiple times. The advance directive forms may be completed during the visit, but aren't required, but you must spend at least 16 minutes counseling about advance care planning to bill for the first 30-minute increment and you may bill additionally in 30-minute increments. It's covered by Medicare if a -33 modifier (preventive care modifier) is added.

Example 1: A 44-year-old male presents for follow-up of well-controlled hypertension and hyperlipidemia. You decide to continue his current doses of losartan and atorvastatin without dose changes.  He continues to smoke ½ pack of cigarettes per day and you counsel him about smoking cessation for 5 minutes.

 → Billing Level:

• • • •  CPT 99214 (established level 4 visit) with 25 modifier and CPT 99406 (smoking cessation counseling 3-10 minutes).
        •  ICD-10: I10 (benign essential hypertension) and E78.2 (Mixed Hyperlipidemia); F17.210 (Cigarette Nicotine dependence, without complication).
        • Example of attestation for tobacco use counseling, “I performed tobacco cessation counseling for 5 minutes, during which we discussed the health benefits of cessation, health risks of continued tobacco abuse, and different options to assist Pt in cessation including different medications and smoking cessation educational options.” 

Example 2: A 66-year-old male presents for an annual physical exam and has no concerns.  There are no abnormalities on the exam.  During his annual exam, you spend 16 minutes discussing advance care directives. 

→ Billing Level:

• • • CPT 99397 (annual physical exam >65yo) with 25 modifier and CPT 99497 (advance directive counseling 1st 30 minutes).
      •  ICD-10: Z00.00 (Annual physical exam without abnormalities); Z71.89 (Advance Directives Counseling).
        • Example of attestation, “I discussed advance directives today, including designating a health care surrogate and making decisions about whether Pt would want CPR, pressors, intubation, IVF, and enteral feeds if incapacitated and unable to make those decisions.  I provided an informational packet for Pt to further consider and return.”

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