Family medicine practitioners provide continuing, comprehensive health care for individuals and families. The scope of family medicine encompasses all ages, genders, each organ system, and every disease entity.
Family medicine practitioners provide most of the care to Americans in underserved rural and urban populations. In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, surgical clearance consultations, chronic pain management, and personalized counseling on maintaining a healthy lifestyle.
Family medicine practitioners also manage chronic illness, often coordinating care provided by other subspecialists. From heart disease, stroke, and hypertension, to diabetes, cancer, and asthma, family medicine practitioners provide ongoing, personal care for the nation’s most serious health problems.
Family medicine practitioners include:
- Medical Doctors (MD)
- Doctor of Osteopathic Medicine (DO)
- Clinical Nurse Practitioners (CNP)
- Physicians Assistants (PA)
Family medicine practitioners care for patients regardless of age or health condition, sustaining an enduring and trusting relationship. While understanding community-level factors and social determinants of health they serve as a patient’s first contact for health concerns.
Did you know at the age of 18 many adults often transfer to Internal Medicine practitioners who specialize in adult medicine only.
Scope of Practice
There are several types of office encounters patients may experience when seeing a family medicine practitioner. These services range from new or established visits, preventative visits, wellness visits for adolescents, minor procedures, vaccines, and more.
Larger scale family medicine offices may offer radiology, laboratory, and physical therapy services for the convenience of their patients.
Let’s begin exploring many of our patient encounter types.
Evaluation and Management
Evaluation and Management codes are divided into a broad category, such as office visits, hospital inpatient or observation care visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient). The basic format of codes with levels of E/M services based on medical decision making (MDM) or time is the same.
We can distinguish new and established patients, professional services as those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services. A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
In the instance where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician.
Example New Patient
New patient Jon Smith 55 years old seen today for a medication management for diabetes. Mr. Smith is new to the area and would like to establish care with our office. He says he has been a diabetic for the last 3 years with no recent hospitalization. Prior to his move he had his yearly eye and podiatry exam both were normal. Mr. Smith states he takes Levemir FlexPen 100 U/ML at the same time daily. He has no other complaints.
Mental Status Exam:
Appearance: weight: 170 pounds; height 5”11; hygiene: clean; casually groomed; neat; well-groomed
Eyes: Inspection of conjunctivae and lids; Examination of pupils and irises (e.g., reaction to light and accommodation, size, and symmetry)
Respiratory: Assessment of respiratory effort
Cardiovascular: Palpation of heart
Gastrointestinal: Examination of abdomen with notation of presence of masses or tenderness; Examination of liver and spleen
Musculoskeletal: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions of lower extremities
Orientation: A&O times 3: date/time, person, place
Assessment and plan:
Type 2 Diabetic E11.9
Levemir FlexPen 100 U/ML
Fasting labs ordered CBC, and A1C
Follow up in 3 months
CPT Code 99203
Signed Jane X MD
Example Established Patient
Established patient Abby Doe 10-year-old seen today for chest tightness, Abby has used her rescue inhaler Albuterol 4 times in the last 24 hours. Abby’s mother states her asthma flares began yesterday morning around 8am with chest tightness felt it was best to bring her in today since symptoms continued. No other symptoms outside of chest tightness. This is the first time in 6 months a patient has encountered an asthma flare. Abby was diagnosed with asthma at the age of 6 years old. No sick contacts nor smoking in the home.
Mental Status Exam:
Appearance: weight: 85 pounds; height 4”10; hygiene: clean; casually groomed; neat; well-groomed
Eyes: Inspection of conjunctivae and lids; Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
Ears, Nose, Mouth and Throat: Otoscopic examination of external auditory canals and tympanic membranes; Inspection of nasal mucosa, septum and turbinate’s; Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx; throat does appear to be red from possible sinus drainage.
Respiratory: Assessment of respiratory effort some crackling and limited airflow.
Cardiovascular: Palpation of heart
Gastrointestinal: Examination of abdomen with notation of presence of masses or tenderness.
Orientation: A&O times 3: date/time, person, place
Assessment and plan:
Acute Asthma Attack J45.901
Prednisone taper 20mg x 4 days, 10mg x 4 days and 5mg x 4 days
Continue to use nasal spray at home
Follow up as needed
CPT Code 99214
Signed Jane X MD
Preventative Visits
For infants and toddlers’ preventative visits are more frequent between birth and 4 years old with a total of 13 wellness visits. These visits include:
· Measurements
· Sensory screening
· Mental, social behaviors
· Behavioral mental health
· Physical examination
· Procedures if necessary
· Anticipatory guidance
· Immunizations
During these visits it is a great time to discuss, child’s development, and safety in the home and at school. It is good to make a list of topics you want to talk about with your child’s pediatrician such as development, behavior, sleep, eating or getting along with other family members.
Beginning, at the age of 4 children will begin receiving yearly preventative visits throughout adolescents, teenage years, into adulthood. These visits should be billed with new or established preventative visit codes which range from 99381-99387 new patients and 99391-99397 established patients.
When vaccines are administered during wellness visits modifiers 25 should be used on the E/M code to represent a separately identifiable visit. Vaccines should be billed with counseling codes if counseling was performed. If counseling was not performed there separate administrative CPT codes to be used. Our next set of CPT codes will represent the types of vaccines administered by listing each code multiple times or use times (x) symbol and indicate number given.
Modifier -51 should not be reported for the vaccines, toxoids when performed with these administration codes (90460-90474)
Example of pediatric wellness visit
A 4-month-old female established patient presents for her checkup. The mother states that the patient drinks 4 oz bottles every 2-3 hours, wakes up once during the middle of the night. No concerns for any developmental delays. Physical exam is normal height and wight within normal limits for her age. Will see her back for a 6-month wellness visit.
The following vaccines are ordered: Pentacel (diphtheria-tetanus-acellular pertussis [DTaP], Haemophilus influenzae type b [Hib], inactivated poliovirus [IPV]), pneumococcal, and rotavirus. The physician counsels the parents on all of them, consent is obtained, and the nurse administers them all.
Assessment and plan:
· 99391 modifier 25 Preventive medicine service, established patient, <1 year diagnosis code Z00.129 Routine child health exam without abnormal findings
· 90698 DTaP-Hib-IPV (Pentacel) product diagnosis code Z23 Encounter for Immunization
· 90670 Pneumococcal product Z23 Encounter for Immunization
· 90680 Rotavirus vaccine, oral use Z23 Encounter for Immunization
· 90460 (×3) Pediatric IA (Pentacel, pneumococcal, rotavirus), first component diagnosis code Z23 Encounter for Immunization
· 90461 (×4) Pediatric IA (Pentacel), each additional component diagnosis code Z23 Encounter for Immunization
Example of adult wellness visit
An 18-year-old female patient presents to the office for her annual checkup and to complete a college physical examination (in college the patient will be living in a dormitory). Patient has no complaints is excited to start her first year of college. Will be rooming with a friend from high school. Parents also have no major concerns currently. The patient is healthy with a normal physical exam and due for a Tdap booster, meningococcal vaccine, first HPV (9-valent) vaccine, and influenza vaccine. The physician counsels the patient and mother only on the meningococcal and HPV vaccines, and the nurse administers each. The patient is asked to return in 4 to 6 weeks (about 1 and a half months) for her second HPV vaccine before she leaves for school.
Assessment and plan:
· 99395 modifier 25 Preventive medicine service, established patient, 18 years or older Z00.0 General adult medical exam without abnormal findings and Z02.0 Encounter for examination for admission to educational institution
· 90734 Meningococcal (MCV4) product Z23 Encounter for Immunization
· 90651 HPV (9-valent) product Z23 Encounter for Immunization
· 90460 (×2) Pediatric IA (meningococcal and HPV), first component Z23 Encounter for Immunization
· 90715 Tdap product Z23 Encounter for Immunization
· 90472 (×2) IA, each additional injection (Tdap) Z23 Encounter for Immunization
90686 Influenza virus vaccine, quadrivalent, preservative free, 0.5 mL dosage Z23 Encounter for Immunization
When a patient is present to the office for a preventative visit, and they are sick, a sick visit can be billed with modifier 25 listed on the wellness visit. The E/M code is selected on MDM or Time. If time is a factor when selecting a code level for the sick visit, remember any time spent on the patient’s wellness visit is not counted.
Medicare Wellness
Traditionally, patients 65 years of age or older with Medicare or Medicare Advantage Plan. Medicare and Medicare Advantage Plan requires the use of HCPCS codes which are based on patients Medicare enrollment date, first 12 months from date of enrollment, then following 12 months and subsequent visits thereafter.
If a patient does not complete their Welcome to Medicare Visit G0402 within the first 12 months following enrollment, the visit should be billed with G0438 Annual wellness visit.
The goal of an Annual Wellness Visit is to create an individualized plan to maintain your health. Items addressed during this visit include:
· Vital signs, height and weight
· Health history update, including allergies
· Hearing screening
· Advanced Care Planning
· Review of your current medications, vitamins and supplements
· Depression screening
· Cognition screening
· Mobility screening
· Vaccination review
You can bill an E/M code with G0402, G0438, and G0439 when a sick visit is performed, discussion about chronic conditions. When not to use E/M codes when only medication refills are performed. Items ordered such as labs, EKG, bone density, mammograms, colonoscopy are items not counted in MDM when selecting an E/M code level. These screenings are included in Medicare Wellness Codes.
Some Medicare Advantage Plans will allow for wellness visits and Medicare Wellness Visits to be billed together. Straight Medicare for example: National Government Services Medicare (NGS) will only accept G0402, G0438 and G0439.
Minor Office Procedures
Our family medicine practitioners may also perform minor office procedures. A minor procedure is performed using injected anesthetic or topical cream anesthetic applied to the site of the procedure. These procedures are performed safely and quickly with few to no complications.
These procedures include cerumen removal, removal of stitches, wart removal, joint injections, ganglion cyst removal and many more minor procedures.
Cerumen is a build-up of earwax and is a common problem that can often be treated using eardrops bought from a pharmacy. Which leads us to one of the most common procedures is the removal of cerumen from the ears. This usually happens when earwax that is produced in our ear does not pass freely but builds up over time.
When stitches are placed in the emergency room or urgent care then removed in the office the visit should be billed with an E/M code.
Many patients receive their cortisone joint injections in the office of the PCP illuminating seeing an orthopedic provider.
Other common minor office procedures:
· Foreign body removal
· Removal ganglion cyst
· Ingrown toenail removal
· Abscess drainage
Example:
· Osteoarthritis (M19.90) is often treated with this method)
· Major joint/bursa: 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa is usually done for osteoarthritis
Remember if a patient comes in for an E/M visit and has a minor procedure performed that modifier 25 goes on the E/M code. If a patient is scheduled for a procedure a separate E/M visit should not be billed except for a reason outside of the reason for the procedure.
In closing, regular consistent visits create strong, communicative, trustworthy relationships between patients, families, and family medicine practitioners.
Conclusion
As you can see, medical coding and billing for family medicine services is very complex with codes scattered between many ages and services. This is proven with the variety diagnosis and preventative visits code selections,
For assistance with this process, please do not hesitate to reach out to us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management.
Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.
