Do I bill the preventive service code (e.g. 99396) and then add the evaluation and management (E/M) code (e.g. 99214) with modifier -25, or do I bill the E/M code and then add the preventive service code with modifier -25?

Billing Preventive Care with Same-Day Problem-Focused E/M Services

Bill the preventive service code (99396) as the primary code, then add the problem-focused E/M code (99214) with modifier -25 appended to the E/M code, not the preventive code. 1

Correct Billing Sequence

The preventive care code (99381-99394) is billed first, and when a separate, significant, and identifiable E/M service is provided on the same day, you bill the appropriate problem-focused E/M code (such as 99214) with modifier -25 appended to that E/M code. 1, 2

The modifier -25 is attached to the problem-focused E/M code (99214), not to the preventive care code (99396). 1 This signals to the payer that a separately identifiable evaluation and management service was performed beyond the preventive care visit.

When to Use This Billing Approach

This billing method is appropriate when health problems are identified during the preventive care visit that require separate evaluation and management beyond the scope of the wellness examination. 1

The American Academy of Pediatrics specifically recommends that insurers recognize the -25 modifier to allow for same-day treatment of issues that would otherwise require another separate health care visit. 1 This represents an important window of opportunity for addressing problems in a timely manner and reducing the risk of loss to follow-up. 1

Documentation Requirements

The problem-focused E/M service must be separately identifiable and significant enough to warrant its own billing code. 1 This means:

• The problem addressed must be distinct from the routine preventive care services 1
• Documentation must clearly show the additional work performed for the acute or chronic problem 1
• The E/M service must meet the criteria for the level billed (99214 requires 30-39 minutes total time OR moderate complexity medical decision-making) 3, 4

Common Pitfalls to Avoid

Do not append modifier -25 to the preventive care code (99396). 1 The modifier always goes on the problem-focused E/M code. 1

Do not use standard office visit codes (99211-99215) as the primary code for routine wellness care when dedicated preventive care codes exist. 2 The preventive care code should be the primary service when a wellness examination is performed. 2

Ensure the problem-focused E/M service is truly separate and identifiable from the preventive care visit. 1 Minor issues that are part of routine health maintenance should not be billed separately. 1