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Provider Manual

Other HealthCheck Coding

Last Updated on August 28, 2018

There may be instances in which evaluation and management (E & M) codes are used in addition to the HealthCheck code. Per the American Medical Association (AMA) guidelines of the CPT Code Manual:

“If an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E & M service, the appropriate Office/Outpatient code 99201 – 99215 should also be reported. Modifier ’-25’ should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.”

“An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service, and which does not require additional work and the performance of key components of a problem-oriented E & M service should not be reported.”

In reviewing this process with the State Managed Care Consultants and Billing and Policy staff (fee-forservice), Security Health Plan was advised that the incidence of billing for a HealthCheck exam and E & M service should not be the routine billing protocol. The comprehensive nature of the HealthCheck exam, which includes multiple components, is already recognized by the enhanced reimbursement. One of the purposes of the HealthCheck exam is to identify problems and pursue prompt treatment. However, not all problems identified will be significant enough to require additional time to evaluate and treat. For example, if an ailment or disease is discovered during the routine examination, and there is no further management except to prescribe an antibiotic, and/or in many cases, simply to advise the parent in comfort measures, very likely this would not be a significant problem that would allow for additional E & M billing. In the event the ailment or disease is complicated and requires extensive assessment and management during the office visit, it would be appropriate to bill the E & M visit.

To determine the significant nature of an additional E & M billing associated with a HealthCheck exam, Security Health Plan’s policy is to request a copy of the medical record for any such billed visits. The service will be reviewed to ensure the service meets the “significant” definition of the AMA billing policy.

For more information on HealthCheck Coding, please refer to the ForwardHealth portal.