United HealthCare - Preventive Medicine and Screening Policy

Preventive Medicine services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) codes G0402, G0438-G0439] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of one of the following problem-oriented E/M service codes 99201-99205 or 99212-99215 only when that code is appended with modifier 25. If the problem-oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Note: G0438 & G0439 by description are “annual” codes and can only be reported once per 365 days.

For more information see the Time span policy and also the list of Time span codes.

When a Preventive Medicine service and an E/M service from the following code series--CPT codes 99211, 99241-99245, 99251-99255, 99281-99285, HCPCS codes G0245-G0246, M0064--are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination (G0101); prostate cancer screening/digital rectal examination (G0102); and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory (Q0091). These screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Annual Gynecological services (S0610-S0613) are included in (and not separately reimbursed from) Preventive Medicine codes.

Prolonged services (99354-99355) are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services (99401-99412, G0396-G0397, G0436-G0437) are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services (97802-97804, G0270-G0271) are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening (99172) and visual acuity screening (99173) are included in (and not separately reimbursed from) Preventive Medicine services.

Reimbursement Guidelines

Preventive Medicine Service and E/M Service 99201-99205, 99212-99215

A Preventive Medicine CPT or HCPCS code (99381-99397, G0402, G0438-G0439) and a problem-oriented E/M CPT code from the following code series only—99201-99205, 99212-99215--may both be submitted for the same patient by the same specialty physician or other health care professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, UnitedHealthcare will reimburse the Preventive Medicine code plus 50% of the problem-oriented E/M code. UnitedHealthcare will not reimburse a problem-oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code (99381-99397, G0402, G0438-G0439) and a problem-oriented E/M CPT or HCPCS code from the following series--99211, 99241-99245, 99251-99255, 99281-99285, G0245-G0246, M0064--may both be submitted for the same patient by the same specialty physician or other health care professional on the same date of service. However, UnitedHealthcare will only reimburse the Preventive Medicine CPT or HCPCS code.

Screening Services

The comprehensive nature of a Preventive Medicine code (99381-99397, G0402, G0438-G0439) reflects an age and gender appropriate examination. When one of the following HCPCS screening codes--G0101, G0102, Q0091--is billed with a Preventive Medicine code (99381-99397, G0402, G0438-G0439) on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.

Annual Gynecological Services

The comprehensive nature of a Preventive Medicine code (99381-99397, G0402, G0438-G0439) reflects an age and gender appropriate examination. When one of the following HCPCS annual gynecological codes—S0610, S0612, S0613—is billed with a Preventive Medicine code on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.

Prolonged Services

According to CPT, the use of the time based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT codebook. When prolonged service add-on codes (99354-99355) are billed with a Preventive Medicine code (99381-99397, G0402, G0438-G0439) on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.

Counseling Services

Preventive Medicine services include counseling. When counseling service codes (99401-99412, G0396-G0397, G0436-G0437) are billed with a Preventive Medicine code (99381-99397, G0402, G0438-G0439) on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.

Medical Nutrition Therapy Services

According to CPT, for medical nutrition therapy assessment and/or intervention performed by a physician, report evaluation and management or preventive medicine service codes. When medical nutrition therapy codes (97802-97804, G0270-G0271) are billed with a Preventive Medicine code (99381-99397, G0402, G0438-G0439) on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.

Visual Function and Visual Acuity Screening

The comprehensive nature of a Preventive Medicine code (99381-99397, G0402, G0438-G0439) reflects an age and gender appropriate examination. When visual function screening (99172) or visual acuity screening (99173) is billed with a Preventive Medicine code (99381-99397, G0402, G0438-G0439) on the same date of service by the same specialty physician or other health care professional, only the Preventive Medicine code is reimbursed.