Prevention and illness management in the Same encounter for 2021


If a provider sees a patient for a wellness service or preventive exam (e.g., annual well woman exam) and also addresses concerns or chronic conditions, we’ve previously held the problem-oriented E/M to a lower level due to the comprehensive nature of the wellness service and difficulty carving out sufficient history and exam to support a higher level of problem-oriented E/M service. Now, with the problem-oriented E/M needing only the support of the medical decision-making component, can we assign a higher level such as 99214 in addition to the wellness service?


Continue to set best practice standards and policies that require a well-documented wellness service and a well-documented illness service. BCA continues to recommend that the illness work be documented to the same level of detail that it would be if the patient presents exclusively for the illness or concern. While history and exam have been removed as components of code selection, proof of medical necessity has not faltered in it’s importance. In general, BCA does not recommend assigning the illness management code higher than 99213/99203, even under the new guidelines. With this said, exceptions certainly may exist. However, one must consider whether the focus shifts to illness management and prevention measures are largely set aside; if so, assign only 99214 (if supported). As an area of potential abuse, it is important that the documentation clearly supports problem evaluation and management versus brief conversations and/or simple refills. Watch for AMA and/or CMS clarification on this important topic as we continue to move through 2021.