Documenting a Preventive Visit

By: Ellen Risotti, BS, CPC, CEMC, CFPC

Annual preventive exams have been a standard of care in the medical industry for many years. CPT describes these services as a periodic comprehensive preventive medicine evaluation (or reevaluation) and management of an individual. CPT codes 99381-99387 are the codes used to represent these services and their selection is based on whether the patient is new or established as well as the patient’s age. CPT goes on to describe the services to include an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

Unlike other evaluation and management services in the CPT book, annual preventive exams do not have specific documentation guidelines required to support the service that is being provided. A preventive medicine service is considered to be of a comprehensive nature however the “comprehensive” nature of these services is not synonymous with the comprehensive examination required in other evaluation and management codes. So the age old question, what constitutes a comprehensive history and exam in relation to a preventive medicine service?

Here at Indianapolis Medical Management (IMM) this topic has brought much debate. Some of the many services that we offer include chart reviews and provider education. When these functions are performed around preventive services, the question of how these services should be documented comes up. What types of information should we expect to see to constitute a comprehensive history? What equates to an age and gender appropriate examination? What types of counseling, anticipatory guidance and risk factor reductions should be addressed? What laboratory and diagnostic procedures would be relevant to a preventive service? What should we be educating physicians and non-physician practitioners (NPPs) to document in a patient’s medical record to support the billing of a preventive medicine evaluation and management service?

Again, there are no official, specific documentation guidelines, so in an effort to help streamline this process for both our team of billing and coding consultants and our clients, we have done extensive research and come up with best practice guidelines based on recommendations from the American Medical Association (AMA), the American Academy of Family Physicians (AAFP), the U.S. Preventive Services Task Force (USPSTF), the American College of Physicians (ACP) Internal Medicine and the American College of Obstetrics and Gynecology (ACOG). These guidelines will be used to evaluate these services. The following breaks down the information that we would expect to see documented in the review of a preventive medicine service based on the patient’s age and gender.

Well Baby Visits – Birth to 2 Years

History: Past illnesses, surgeries, medications, allergies, pregnancy/birth history, family history and social history

Exam: Hearing for newborns, weight, length, head circumference, head, chest, abdomen, genitalia, neck, extremities, eyes, ENT, cardiovascular, respiratory, skin, neurological

Counseling/Anticipatory Guidance: Safety, health, nutrition, development, immunizations


Risk Factors: Age appropriate developmental and behavioral assessments

Lab/Diagnostic Services: Hemoglobin or hematocrit once between 9-12 months, lead testing at 1year and 2 years if uncertain about lead exposure, PKU screening

Well Child Visits – 3 to 10 Years

History: Past illnesses, surgeries, medications, allergies, family history and social history

Exam: Blood pressure, vision screen, hearing screen, height, weight, BMI, w/percentiles for age, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological

Counseling/Anticipatory Guidance: safety, injury prevention, health, nutrition, development, immunization, screenings

Risk Factors: Age appropriate developmental and behavioral assessments

Lab/Diagnostic Services: Any warranted based on risk factors

Well Child Visits – 11 to 18 Years

History: Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam: Blood pressure, vision screen, hearing screen, height, weight, BMI, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, avoidance of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunization, screenings

Risk Factors: hypertension, hyperlipidemia, coronary heart disease, depression, eating disorders, emotional, physical, or sexual abuse, problems with learning and school

Lab/Diagnostic Services: Chlamydia screening for sexually active females,

Adult Visits – 19 to 39 Years

History: Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam: Blood pressure, height, weight, BMI, breast exam for women, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: nutrition, family planning/contraception, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunizations, screenings

For Women: Breast cancer and self breast exams


Lab/Diagnostic Services: Cholesterol every 5 years beginning at 20 years, Chlamydia for sexually active women under 25, cervical cancer

Adult Visits – 40 to 64 Years

History: Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions


Exam: Blood pressure, height, weight, BMI, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, contraception, dental health, mental health, immunizations, screenings

Lab/Diagnostic Services: Cholesterol, diabetes, colorectal cancer beginning at 50 years

For Women: Breast cancer, cervical cancer

For Men: Prostate cancer beginning at 50 years



Adult Visits – 65 Years and Older

History: Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam: Blood pressure, height, weight, BMI, hearing screening, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior, dental health, mental health, immunizations, screenings

Lab/Diagnostic Services: Cholesterol, diabetes, colorectal cancer

For Women: Breast cancer, cervical cancer, osteoporosis beginning at 65

For Men: Abnormal Aortic Aneurysm one time for men 65-75 years with history of smoking, prostate cancer

It is important to note that checking the status of chronic conditions and refilling on-going prescriptions is expected during the course of an Annual Preventive Exam and thus would not warrant the billing of a separate Problem Oriented Evaluation and Management service. However, if a chronic condition is not being well controlled and decisions are being made as to how to treat the patient to improve control, changing the dosage of medications, changing to a new medication etc, this may substantiate a separate Problem Oriented Evaluation and Management service if more work is done (and documented) than what would normally be performed in the course of an Annual Preventive Exam.

In closing, please keep in mind, the above recommendations are just that, recommendations. The individual needs of the patient and their history and risk factors will determine the extent to which counseling, anticipatory guidance and screening services should be performed. For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended. What is important to remember is the documentation should include what counseling and anticipatory guidance was provided to each patient as well as the screenings that were discussed and ordered or offered, should the patient decline. The documentation should very clearly show that the elements of the Annual Preventive service were met. At IMM, it is our hope to provide information and education that will help our clients improve on documentation and thus help ensure that the services performed are supported by that documentation. Hopefully this article will help you in your documentation of Preventive visits.

© 2011 Efficiency in Practice

Ellen Risotti, CPC, CEMC, CFPC is a billing and coding consultant for Indianapolis Medical Management and a contributing author to Efficiency in Practice. Efficiency in Practice is the free eNewsletter for medical practice managers who want to save time, money and reduce risk . To read more articles like this, visit www.efficiencyinpractice.com and subscribe free of charge. This article can be reprinted freely online, as long as the entire article and this resource box are included.