“In medicine, what we don’t document kills us—not only
clinically, but financially.” —AMA commentary on billing
transparency
Sarah, a 45-year-old mother of two, thought her preventive
physical was fully covered by insurance. She got her routine bloodwork,
reviewed vaccines, and had a standard wellness check. Before leaving, she
casually mentioned nagging knee pain. The doctor examined it, made a plan, and
ordered an X-ray.
Weeks later, Sarah received a bill. The preventive part was
covered, but the knee exam was billed separately as a problem-focused visit,
leaving her with an unexpected balance. She felt blindsided — and she’s not
alone.
This scenario is playing out in clinics everywhere, leaving
patients confused and practices struggling to explain coverage rules. Understanding
the difference between preventive and problem-focused visits is essential —
not just for coding accuracy but also for patient trust and financial
transparency.
Why This Matters Now
The AMA’s August 2025 guidance confirmed that
physicians can bill for both preventive/wellness and problem-focused
E/M services during the same visit — but only when the problem portion is significant,
separately identifiable, and documented with modifier-25.
This matters more than ever because:
- CMS’s
proposed 2026 Medicare Fee Schedule may affect reimbursement for these
visits.
- Patients
are increasingly frustrated by “surprise bills,” which can damage
satisfaction scores and retention.
- Commercial
payers are scrutinizing modifier-25 claims more closely, making accurate
documentation critical.
Statistics: Modifier-25 Billing Trends and Compliance
Risks
- $124
million: Medicare paid this amount for evaluation and management
(E&M) services billed with modifier-25 on the same day as intravitreal
eye injections during the audit period from June 2022 through May 2023 Office of Inspector General.
- 42%:
This percentage of intravitreal injections were accompanied by E&M
services billed with modifier-25, allowing claims to bypass system edits
designed to prevent improper payments Office of Inspector General.
- 92%:
In a sample of 24 E&M services billed with modifier-25, 22 lacked
adequate documentation to support the modifier's use, indicating a high
rate of noncompliance LinkedIn.
- $427,129.11:
A Connecticut physiatrist and her practice agreed to pay this amount to
settle federal allegations of improper Medicare billing, including the
inappropriate use of modifier-25 on E&M services during the period
from April 2017 to November 2019 Stamford Advocate.
- 35%:
In a 2002 audit, Medicare allowed 35% of claims using modifier-25 that did
not meet program requirements, resulting in $538 million in improper
payments GovInfo.
These statistics highlight the ongoing challenges and risks
associated with the improper use of modifier-25 in billing practices. They
underscore the need for healthcare providers to ensure accurate documentation
and adherence to coding guidelines to avoid potential audits and financial
penalties.
Expert Round-Up: Opinions & Advice
Dr. Mary Chen, MD, Family Physician: “When you go
beyond screening, vaccines, and counseling — and treat a new or worsening
problem — document it clearly and bill both visits. Half-measures create risk.
Good documentation is your protection.”
Janet Thompson, CPC, CPB: “Modifier-25 is essential
but can trigger audits. Use it only when the additional work is truly
significant. Separate history, exam, and decision-making notes clearly.”
Dr. Alan Martinez, Healthcare Policy Analyst:
“Patient education is half the battle. Tell patients before you start: ‘If we
address additional issues today, insurance may treat that differently.’ It
prevents friction later.”
Tactical Advice & Practical Tips
Here’s how to handle mixed visits the right way:
- Define
“significant and separately identifiable.” Make sure your practice has
clear internal guidelines.
- Use
modifier-25 properly. Attach it to the problem-focused E/M service
only when extra work was done.
- Train
staff and providers. Run internal chart audits, share payer rule
updates, and standardize documentation practices.
- Communicate
upfront. Tell patients at check-in that additional problems may create
additional charges.
- Check
payer policies. Medicare allows it, but commercial insurers vary —
confirm specifics.
- Document
clearly. Use separate note sections or templates for preventive vs.
problem-focused work.
Questioning “Best Practices”
Many clinics assume they are billing correctly — but find
themselves under-coding, over-coding, or facing denials. Common failures
include:
- Not
clearly separating documentation between preventive and problem portions.
- Overusing
modifier-25 for minor issues.
- Not
informing patients in advance, leading to surprise billing complaints.
- Ignoring
commercial payer rules and relying only on Medicare guidance.
- Missing
revenue opportunities by billing preventive only even when additional work
was done.
Myth Buster Section
Myth 1: You cannot bill preventive and
problem-focused services on the same day.
Truth: You can — as long as the additional work is significant,
separately identifiable, and documented with modifier-25.
Myth 2: Everything discussed during a preventive
visit is included in the preventive code.
Truth: If a new complaint leads to additional examination, tests, or
treatment, that portion may be billed separately as a problem-focused visit.
Myth 3: Preventive visits are always free to
patients.
Truth: Patients may owe copays, coinsurance, or deductibles for
the problem-focused portion of the visit. Clear communication avoids
frustration.
Recent News: Scrutiny Intensifies Around Modifier-25
Usage
In recent months, healthcare providers have faced increased
scrutiny over the application of modifier-25, which indicates a significant,
separately identifiable evaluation and management (E/M) service performed on
the same day as a procedure. The U.S. Department of Health and Human Services
Office of Inspector General (OIG) conducted an audit revealing that Medicare
paid approximately $124 million for E/M services billed with modifier-25 during
the same visit as intravitreal eye injections. Alarmingly, 42% of these claims
lacked adequate documentation to support the modifier's use, highlighting a
prevalent issue of improper billing practices Office of Inspector General.
The Centers for Medicare & Medicaid Services (CMS) has
acknowledged these concerns and is taking steps to address them. CMS has been
urged to update Medicare requirements for billing E/M services provided on the
same day as certain procedures, such as eye injections, to help providers
understand the appropriate use of modifier-25. Recommendations include
clarifying the definition of a "significant and separately
identifiable" E/M service and identifying circumstances that allow for an
E/M service to be billed on the same date of service as a procedure Office of Inspector General.
In response to these developments, healthcare organizations
are being advised to exercise caution and ensure that any E/M services billed
with modifier-25 are well-documented and truly separate from the primary
procedure. This includes providing clear documentation that justifies the
necessity of the additional E/M service and demonstrates that it goes beyond
the usual preoperative and postoperative work associated with the procedure.
Real-Life Case Study
A Midwest clinic discovered they were routinely
under-billing when patients brought additional complaints to preventive visits.
They:
- Flagged
mixed visits at scheduling.
- Updated
EHR templates to separate preventive vs. problem documentation.
- Created
a patient acknowledgment form explaining potential charges.
- Trained
providers and billing staff on payer-specific rules.
Outcome: Within six months, revenue increased by
nearly 50% on mixed visits, denials dropped, and patient complaints decreased
by 70%.
Legal Implications, Practical Considerations, and Ethical
Considerations
Legal Implications:
Proper documentation and accurate coding are not just best practices—they
protect your practice from legal risk. Misrepresenting a visit as purely
preventive when significant problem-focused care was delivered can lead to audit
findings, insurance fraud allegations, or penalties. Modifier-25 misuse is
a common audit trigger, so always ensure that the problem-focused portion is
clearly documented as significant and separately identifiable. Staying
current with AMA CPT guidelines, CMS rules, and payer-specific policies
helps safeguard both compliance and reimbursement.
Practical Considerations:
From a day-to-day perspective, managing mixed visits requires workflow
adjustments, staff training, and effective communication with patients.
Practices should implement EHR templates that separate preventive and
problem-focused sections, flag mixed visits during scheduling, and provide
clear cost estimates for patients. Providers must balance thorough
clinical care with efficient documentation. Regular audits, staff refresher
training, and clear SOPs ensure consistency, minimize denials, and reduce
patient confusion.
Ethical Considerations:
Ethically, transparency is key. Patients deserve to know when additional
services may incur costs, even during a preventive visit. Providers should
avoid under-coding or over-coding to manipulate reimbursement, as both
can harm patient trust and violate professional standards. Ethical billing
practices include informing patients in advance, documenting work
accurately, and applying coding rules fairly. Doing so fosters patient
confidence, strengthens the provider-patient relationship, and aligns practice
management with broader ethical standards in healthcare.
By addressing these three pillars—legal, practical, and
ethical—clinics can provide high-quality care while protecting revenue,
maintaining compliance, and preserving patient trust.
Frequently Asked Questions (FAQ)
Q1: What’s the difference between a preventive and a
problem-focused visit?
A1: Preventive visits cover screenings, immunizations, and wellness
counseling. Problem-focused visits address new or worsening complaints that
require medical decision-making, tests, or treatment.
Q2: Can I bill both services together?
A2: Yes — if the additional work is significant, separately
identifiable, and documented, you can bill both using modifier-25.
Q3: Will patients pay more?
A3: Often yes. The preventive part may be covered fully, but the
problem-focused portion may trigger copays, deductibles, or coinsurance.
Q4: Do I need two separate notes?
A4: No, but documentation must clearly differentiate between preventive
and problem-focused services.
Tools, Metrics, and Resources for Managing Mixed
Preventive + Problem-Focused Visits
Tools:
- Electronic
Health Records (EHR) Templates: Create separate sections for
preventive and problem-focused services. Include prompts for MDM or
time-based documentation and automatic flags for mixed visits.
- Scheduling
Software: Add flags at the appointment level to indicate “wellness +
possible problem” to prepare staff and providers in advance.
- Patient
Communication Tools: Digital check-in forms or portal notifications
that alert patients about potential copays for problem-focused care.
- Coding
and Billing Software: Ensure your system supports modifier-25 and can
generate audit-friendly claims reports. Some advanced platforms can
auto-flag claims at risk for denials.
- Audit
and Quality Assurance Tools: Use internal dashboards to monitor denial
rates, documentation gaps, and revenue capture for mixed visits.
Metrics:
- Modifier-25
Utilization Rate: Track the percentage of preventive visits with an
attached modifier-25 for problem-focused care.
- Denial
Rate for Mixed Visits: Measure how often claims are denied due to
documentation or coding errors.
- Revenue
Capture: Compare billed vs. potential revenue for mixed visits to
identify undercoding.
- Patient
Satisfaction: Survey patients post-visit to assess clarity of billing
communication and overall experience.
- Documentation
Quality: Audit a sample of charts to ensure preventive vs.
problem-focused work is clearly separated and justified.
Resources:
- AMA
CPT Guidelines (2025 Update): Offers detailed guidance on preventive
vs. problem-focused coding and proper modifier use.
- CMS
2026 Proposed Medicare Physician Fee Schedule: Provides insight on
upcoming policy changes affecting preventive and problem-focused visits.
- Health
Care Dive Articles on Billing Trends: Useful for staying current on
payer updates, denials trends, and value-based care implications.
- Professional
Networks: Join groups like the American Academy of Family Physicians
(AAFP) or American Health Information Management Association (AHIMA) for
webinars, coding updates, and peer discussion.
- Internal
Training Materials: Develop a practice-specific playbook covering
scripts, documentation templates, and audit procedures.
These tools, metrics, and resources allow practices to optimize
documentation, reduce denials, maximize revenue, and improve patient
communication while staying compliant with evolving billing rules.
Step-by-Step: Handling Mixed Preventive + Problem-Focused
Visits
- Pre-Visit
Screening — Owner: Scheduling / Front Desk
Ask at booking: “Do you have any concerns beyond the annual wellness exam?” If yes, flag the appointment as wellness + potential problem and note the complaint in the appointment reason. This sets expectations early and reduces surprises. - Check-In
& Consent — Owner: Front Desk / MA
At check-in, confirm the concerns documented at booking. Give a short, clear line to the patient: “If we address that issue today, your insurer may treat that part differently and you might have a copay or deductible.” Offer a one-sentence written acknowledgment the patient can sign. - Triage
& Prep — Owner: Nurse / MA
Record vitals and list the patient’s preventive needs. Document any additional complaints in the intake note. Put a visible flag in the chart (e.g., “Mixed visit — possible E/M”). This helps the provider prepare. - Structure
the Encounter — Owner: Provider
Start the note with a clear separation: label a Preventive section and a Problem-Focused section. Do preventive tasks first if you can, then address the complaint — or vice versa — but make the separation explicit in the note. Example lead: “Reason for visit: Annual wellness exam. During review of systems the patient reported new knee pain for 3 weeks (see Problem-Focused section).” - Document
the Problem-Focused Work — Owner: Provider
Write out the history, focused exam, medical decision-making (MDM), and plan for the problem. Be explicit about extra time, testing, or prescriptions. Use statements that show the work was significant and separately identifiable (e.g., “Performed focused musculoskeletal exam and ordered knee X-ray; discussed treatment options and initiated NSAID therapy.”). - Capture
Time or MDM (if used for coding) — Owner: Provider/Coder
If your practice codes by time, record the total face-to-face time and how much of it was spent on the problem. If using MDM, document the complexity (diagnostic options, risk, and tests ordered). Clear MDM reduces audit risk. - Coding
& Modifier Use — Owner: Coder / Billing
On the claim: include the preventive/wellness CPT code and the E/M office visit code for the problem. Attach modifier-25 to the E/M line to indicate a separate, significant service. Ensure diagnosis codes point appropriately to each service in the claim. - Financial
Counseling at Checkout — Owner: Front Desk / Billing
Provide a brief cost estimate for the problem portion when possible. Offer to run a benefits check. Give the patient a printed explanation: preventive = often covered; problem portion = may have copay/deductible. Clear communication lowers surprise billing calls. - Claims
Follow-Up & Denial Management — Owner: Billing Manager
Monitor claims for denials related to modifier-25. If denied, pull the chart and build an appeal packet that highlights the separated documentation and MDM. Track denial reasons for trend analysis. - Audit
& Quality Assurance — Owner: Compliance / Clinical Lead
Regularly audit a sample of mixed visits. Look for clear separation in notes, proper use of modifier-25, appropriate diagnosis pairing, and patient communication evidence. Use audit results to update training. - Training
& SOP — Owner: Operations / Medical Director
Create a short SOP that covers scheduling scripts, check-in acknowledgment, note structure, modifier-25 rules, and appeal templates. Run brief monthly refreshers for providers, coders, and front desk staff. - Payer
Policy Maintenance — Owner: Contracts / Billing Lead
Keep a one-page cheat sheet per major payer: rules about preventive vs E/M, modifier rules, frequency limitations, and preauthorization quirks. Update whenever payer policies change. - EHR
Templates & Tech — Owner: IT / Clinical Informatics
Build templates that force separation: a Preventive block and a Problem block. Add a chart flag for “mixed visit.” If available, enable automated prompts that remind clinicians to document MDM or time. - Patient
Scripts & Communication — Owner: Providers / Front Desk
Sample short scripts:
- Scheduling:
“Are we only seeing you for wellness, or do you want to discuss anything
else?”
- Check-in:
“If we treat that issue today, insurance may apply a copay; do you want to
proceed?”
- Provider:
“I’m going to handle your annual wellness items first; then I’ll examine
your knee and we’ll discuss options. I’ll document both parts separately.”
- Continuous
Improvement Loop — Owner: Practice Leadership
Collect feedback: patient satisfaction, denial rates, revenue capture, and staff comfort. Adjust SOPs, update templates, retest training, and celebrate wins.
Quick Checklist (Action Items You Can Use Today)
- Add
“Mixed visit” flag to scheduling options.
- Create
a one-line patient acknowledgment form.
- Update
EHR template to include separate Preventive and Problem sections.
- Run
a one-week chart audit of recent wellness visits to see if mixed problems
were handled but not billed.
- Make
a payer cheat sheet for top 5 plans.
Short Documentation Examples You Can Copy
Lead sentence: “Primary reason: Annual wellness exam. During ROS the patient
reported [problem X] for [duration].”
MDM justification: “Focused exam performed for [problem X]. Ordered [test].
Discussed management options and initiated [treatment]. Problem required
additional decision-making beyond preventive services.”
Updated Guidance & Statistics
- AMA
(August 2025): Confirms physicians may bill both services when
criteria are met and documentation supports it.
- CMS
2026 Proposed Fee Schedule: Could shift reimbursement, making
documentation accuracy more important than ever.
- Chronic
Disease Impact: Roughly 75% of U.S. healthcare costs are tied
to preventable conditions, highlighting why accurate preventive care and
billing matter.
Final Thoughts
Confusion over mixed visits erodes trust and revenue. Clear
documentation, proper use of modifier-25, and proactive patient communication
protect both your practice and your patients.
Future Outlook: The Next Phase of Preventive vs.
Problem-Focused Billing
The way we define preventive care and problem-focused
visits is evolving — and the next few years will bring even more change.
Experts predict:
- AI-powered
documentation tools will flag when a visit meets criteria for separate
billing, helping providers avoid errors and disputes.
- Patient-facing
cost estimators will become more common, allowing patients to see
their out-of-pocket responsibility before the visit is complete.
- Value-based
care models may blur the lines further, with bundled payments
replacing fee-for-service in some settings, making the distinction between
visit types less financially significant.
- Policy
updates are expected from CMS and commercial payers, clarifying rules
for same-day billing as telehealth and hybrid visits become the norm.
The goal will remain the same: clarity, fairness, and
better communication between providers and patients. Staying ahead of these
changes can turn billing from a point of frustration into a point of trust.
Call to Action
Get involved by reviewing your practice’s current
process and training your staff.
Join the movement for billing transparency and share your success
stories.
Take the first step by auditing last month’s preventive visits — you may
find missed revenue or compliance risks.
References
- AMA:
“Can physicians bill for both preventive and E/M services in the same
visit?” — this AMA article clarifies when it is permissible to bill
both services. Read more here American Medical Association
- CMS
Proposed 2026 Medicare Physician Fee Schedule — outlines upcoming
changes to physician payment. Details here CMADocs
- Health
Care Dive: CMS Proposes Rule Aligning Medicare Physician Payment —
analysis of how payment changes could impact preventive and E/M services. Read more here Healthcare Dive
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech, healthcare management, and medical billing. He
focuses on delivering practical insights that help professionals navigate
complex challenges at the intersection of healthcare and medical practice.
Connect with Dr. Cham on LinkedIn: linkedin.com/in/daniel-cham-md-669036285
Disclaimer / Note: This article is intended to
provide an overview of the topic and does not constitute legal or medical
advice. Readers should consult professionals in the relevant fields for
specific guidance.
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