What is the appropriate Evaluation and Management (E&M) code for a routine work physical?

Work Physical E&M Coding

For a routine work physical examination, the appropriate E&M codes are from the preventive medicine services series: 99381-99387 for new patients or 99391-99397 for established patients, selected based on the patient's age. These codes are specifically designed for comprehensive preventive evaluations performed for employment or administrative purposes 1.

Code Selection Framework

Preventive Medicine Codes (Primary Choice)

• Use CPT codes 99381-99397 for routine work physicals, as these are the designated preventive care visit codes 1
• The specific code within this range depends on:
  • Patient status: New patient (99381-99387) versus established patient (99391-99397) 1
  • Age category: Each age bracket has its own code within the series 1

Problem-Oriented Office Visit Codes (Alternative)

If significant abnormalities are identified during the work physical that require additional evaluation beyond the scope of a routine examination:

• New patients: Use 99201-99205 based on complexity 1
  • 99204 for detailed, moderately complex evaluations requiring at least 45 minutes (with more than half spent counseling) 1
  • 99205 for comprehensive, highly complex evaluations requiring 60 minutes (with more than half spent counseling) 1
• Established patients: Use 99210-99215 based on complexity 1
  • 99214 for detailed, moderately complex evaluations requiring at least 25 minutes (with more than half spent counseling) 1
  • 99215 for comprehensive, highly complex evaluations requiring 40 minutes (with more than half spent counseling) 1

Critical Documentation Requirements

Essential Elements

• Document the comprehensive nature of the preventive examination to support the preventive medicine code selection 1
• Record the specific purpose of the examination (employment clearance, return-to-work evaluation, pre-employment screening) 2
• Include all required components: Complete history, comprehensive physical examination, and any counseling provided 2, 3

Modifier Usage

• Append modifier 25 to the preventive care code if a separate, significant problem-oriented E&M service is provided on the same day 1
• This allows billing for both the preventive service and the problem-oriented evaluation when clinically appropriate 1

Common Pitfalls to Avoid

• Do not use consultation codes (99241-99245) for routine work physicals, as these require a formal request for opinion and written report back to the requesting provider 1
• Do not default to problem-oriented codes (99201-99215) for straightforward work physicals, as this misrepresents the service provided 3, 4
• Ensure documentation supports the level of service billed, as inadequate documentation can result in civil monetary penalties, Medicare exclusion, or criminal prosecution 2, 5
• Verify payer-specific requirements, as some insurance plans or workers' compensation programs may have specific coding requirements for occupational health services 2