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Preventive E&M Services
Preventive visits may result in the discovery of signs or symptoms of an illness that require a significant separate medical workup. Two evaluation and management (E&M) services may be reported on the same day. The preventive service would be identified as either new or established codes (99381-87 or 99391-97), according to the patient's age. The appropriate diagnosis code for the preventive service should be included on the claim and associated with the line item, for example, ICD code V70. The second line of service coding would identify the illness segment of the encounter, with the office code selection dependent on the appropriate E&M level of care and whether the patient was new or established to the physician (99201-05, 99211-15). The "25" modifier should be added to the office service to indicate that a significant separately definable E&M service was provided by the same physician on the same date of service. The diagnosis code for the sign(s), symptom(s), or illness must be included on the claim to support the service.
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