If an abnormality/ies is encountered or a preexisting problem is addressed
in the process of performing this preventive medicine evaluation and
management service, and if the problem/abnormality is significant enough
to require additional work to perform the key components of a problem-
oriented E/M service, then the appropriate Office/Outpatient code 99201-
99215 should also be reported. Modifier 25 should be added to the
Office/Outpatient code to indicate that a significant, separately identifiable
Evaluation and Management service was provided by the same physician
on the same day as the preventive medicine service. The appropriate
preventive medicine service is additionally reported.
An insignificant or trivial problem/abnormality that is encountered in the
process of performing the preventive medicine evaluation and management
service and which does not require additional work and the performance of
the key components of a problem-oriented E/M service should not be
reported.
Example: A 50-year-old established patient comes in to the office for an annual wellness visit and at the same time also complains of a severe chest pain.
The physician performs comprehensive preventive evaluation as well as a separate level III elements of an office visit for chest pain and reports it in addition to the preventive medicine service, then the coding can be done as follows:
CPT MOD ICD
99396 V70.0
99214 25 786.50.
