Can I bill 99214 (Current Procedural Terminology code for office or other outpatient visit) with a well exam?

Billing 99214 with Well Exam

Yes, you can bill a 99214 (office or outpatient visit) with a well exam by using the modifier -25 to indicate a significant, separately identifiable evaluation and management service performed on the same day as the preventive service. 1

Coding Requirements for Combined Visits

When billing both a preventive service (well exam) and a problem-oriented visit (99214) on the same day:

1. Use the preventive service code (99381-99397) for the well exam component
2. Add the E/M code 99214 for the separately identifiable problem-based service
3. Append modifier -25 to the E/M code to indicate it's a significant, separately identifiable service 1

Documentation Requirements

To support billing both services, your documentation must clearly demonstrate:

• Separate documentation for the preventive and problem-oriented components
• Medical necessity for addressing the problem during the same visit
• Complexity criteria supporting the 99214 level, which requires:
  • Detailed history and examination
  • Moderate complexity medical decision making
  • OR at least 25 minutes of face-to-face time with more than half spent counseling 1

Billing Considerations

• The preventive service is typically reimbursed at 100% under many insurance plans
• The problem-oriented service (99214 with modifier -25) may be subject to copays, coinsurance, or deductibles 1
• Some payers may have specific requirements or limitations for combined billing

Common Pitfalls to Avoid

• Insufficient documentation: Failing to clearly separate and document the preventive and problem-oriented components
• Incorrect modifier usage: Not appending the -25 modifier to the E/M code
• Undercoding: Research shows significant undercoding occurs in clinical settings, with 72.1% of visits coded at 99213 or lower that could have been coded as 99214 or higher 2
• Overcoding: Much less common but still problematic - only occurs in about 2% of cases 2

Best Practices

• Clearly document the preventive elements separately from the problem-focused elements
• Ensure your documentation supports the level of service billed
• Use time-based billing when appropriate, especially when counseling dominates the visit
• Consider using standardized templates to improve documentation quality 3
• Review payer-specific guidelines as requirements may vary

By following these guidelines, you can appropriately bill for both services when medically necessary and properly documented, ensuring proper reimbursement while maintaining compliance with coding regulations.