Uncomplicating the Annual Physical

June 3, 2024

Providers and coders tend to focus on the complexities of the components, rules, and requirements of AWVs (annual wellness visits) for Medicare patients. Much less attention is devoted to annual physicals for patients under age 65 covered by commercial insurance. When it comes to coding and billing, these “routine physicals” can actually be quite complicated.

So let’s take a closer look at rules and helpful tips for the codes that apply to these visits (99381/99391 through 99387/99397). What’s needed for these under-65 exams? What is included? Can you bill for additional issues addressed at these exams? We’ll get to all these questions and more.

Pediatric Physicals
During their first year, infants come in quite frequently for weight checks. For the first such visit, apply the 99381 code. For all subsequent visits up to the patient’s first birthday, apply 99391. Three physicals are allowed for two-year-olds; that number decreases to two visits when patients reach age 3. After that, the rule of one physical per year applies until age 18.

Developmental Screenings
A developmental screening (96110) is also expected with any 99391-99395 visit up to age 18. These screenings are important for benchmarking patients’ development to ensure they are on track. Pediatric mental health screenings also are performed during these visits. They differ from adult mental health screenings in several important ways, such as monitoring adolescent hormonal mood changes, mental stability, and depression/suicidal feelings.

Need-Based Screenings
Many patients ages 18 through 65 (99385/99395 – 99387/99397) may require screenings more than once a year to monitor certain conditions; often, this need begins when these patients are in their late 40s.

Here are some examples:

  • Smoking cessation (99406/99407): To bill for these, you must record the exact amount of time spent with the patient. The previous time range of 3-10 minutes no longer applies to these visits.
  • Mental health screenings (96160/G0444): It no longer matters whether the result is positive or negative; what counts now is time spent. These screenings require a minimum of five minutes with the patient.
  • Alcohol screenings (99408): Alcohol and/or substance abuse structured screenings and brief intervention services require 15 to 30 minutes with the patient.
  • Advanced care planning (99497): These visits mainly involve patients over age 60 who are not covered under Medicare and are billed by time, with a minimum of 15 minutes. Apply the 99497 code for visits requiring 16-30 minutes. If more time is needed, bill 99498 for an additional 30 minutes.
  • Pap smears and breast exams (Q0091/G0101): These are performed as appropriate.
  • Colo-rectal and breast screenings: These are included in the annual physical and not separately billable.

What if additional issues are addressed at an annual physical examination? Can an additional E/M be added to the physical?
Short answer: Maybe. With annual physicals, the answer is different than it would be for additional E/M added to AWV Medicare-covered exams. Since AWVs are hands-off exams, you may be able to bill for any chronic issues addressed during these visits. By contrast, with annual physicals covered by commercial payors, the answer is generally no: You cannot bill for addressing stable, chronic issues.

However, you CAN bill for additional services if the issues addressed during the annual physical are new or exacerbated. Here’s an example scenario. The patient comes in for a routine physical, but their COPD/asthma—an existing, chronic issue—has worsened since the time the physical was scheduled. You can bill for addressing this issue. Another example: If the patient has a new injury or a new viral illness/cold/flu, and any of these are addressed during the exam, they can be billed on top of the exam. On the other hand, if the provider addresses chronic conditions, such as hypertension or diabetes, and determines that they are stable, you cannot apply additional E/M to the visit.

Save The Date
Mastering Medicare Documentation Webinar: Ensuring Compliance with Updated E/M Guidelines
Thursday, June 6 at 12 p.m. CT.
Don’t miss our next free webinar, when our E/M coding experts will help you ensure that your E/M documentation will withstand increased scrutiny from Medicare. Attendees earn one hour of CEU credit from AAPC.
Click here to register: https://zoom.us/webinar/register/WN_9Ep4_MiCTkmMrGGHZ52tXA

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com


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Michelle Sergei-Casiano
Michelle Sergei-Casiano
Michelle Sergei-Casiano
Senior Manager, Regulatory and Coding Compliance