Despite myths to the contrary, physicians are not prohibited from coding and billing for both preventive and problem-focused evaluation and management (E/M) services when they are performed during the same appointment.

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Motivated by a desire to avoid audits, many physicians tend to undercode for the work they perform. Others, however, are just unaware that the idea that doctors should not bill for both preventive or wellness and E/M services when they are performed during the same visit is based on myth not fact.

The AMA is spreading that message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care and contribute to burnout.

Reducing physician burnout is a core element of the AMA Recovery Plan for America’s Physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And the AMA is ready.

Nearly 40% of U.S. physicians experience burnout. The AMA develops resources that prioritize well-being and highlight workflow changes so physicians can focus on what matters—patient care.

The AMA series is part of the AMA’s practice transformation efforts and provides physicians and their care teams with resources to reduce guesswork and administrative burdens so their focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.

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In the case of billing for both preventive and problem-focused E/M services in the same visit, the significance of the problem addressed, and the amount of time and medical decision-making required help determine how the services are most appropriately billed.

It is important to accurately and completely document all medically appropriate and necessary care performed during a patient encounter, and to bill for what is documented.

The Current Procedural Terminology (CPT®) guidelines provide clarification. If an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive or wellness visit, and the problem or abnormal finding is significant enough to require additional work to perform the key components of a problem-focused E/M service, then the appropriate office or outpatient E/M code should also be billed.

Modifier-25 should be added to the office or outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

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When billing Medicare, the Centers for Medicare & Medicaid Services requires that additional qualifying E/M services be billed separately from the preventive service. 

Commercial payers, however, may or may not cover the additional problem-focused E/M service billed at the same visit as the preventive service. It depends on the patient’s specific policy, Whether the services are being billed to a commercial payer or Medicare, using Modifier-25 properly will help ensure the charges eligible for payment are processed correctly.

Physicians and members of their care team are invited to submit queries about misinterpreted regulations that might be diverting their time from patients. Email the practice transformation team directly at [email protected]n.org.

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