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Coding Preventive Evaluation and Management Services – May 2011

The new health care reform law (the Affordable Care Act or “ACA”) requires certain defined preventive care services to be covered with no member cost-sharing when rendered by in-network providers. Preventive evaluation and management services are included in the defined preventive care services paid at 100%.  
To ensure your patients appropriately receive these benefits, Empire encourages physicians and other providers to use correct coding guidelines when reporting preventive evaluations. There are specific preventive medicine service codes indicated in the Preventive Medicine Services subsection of the 2011 CPT Professional Edition coding manual (e.g. 99381– 99387 and 99391-99397). Additionally, preventive evaluation HCPCS codes are provided in the HCPCS Level II 2011 reference manual (e.g. G0402, G0438, G0439). Both sets of codes can be separately reported for preventive evaluation services as long as documentation and criteria are met to support the use of these codes.  
In the event that an abnormality is encountered or a pre-existing problem is significantly addressed during the process of performing a preventive exam, the 2011 CPT Professional Edition provides details on when and how to report a problem oriented evaluation and management code (e.g. 99201-99215) in conjunction with the preventive exam. We encourage familiarity with these guidelines to facilitate appropriate and accurate claim processing in accordance with the member’s benefit plan. 
It is important to remember that not all benefit plans are subject to the new preventive care coverage requirements, so providers should continue to verify eligibility and benefits through their normal business processes when determining copayments or coinsurance due by members for services rendered. 
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