What is the general approach to coding preventive services such as adult physicals?

• A. Use the most appropriate preventive service code based on age and risk, with documentation
• B. Use preventive service code designed for the age/gender and risk factors
• C. Use general CPT code 99213
• D. Use diagnostic codes only

Answer: (B)

When coding preventive adult physicals, you select the preventive medicine code that is specifically designed for the patient’s age and gender, and consider any risk factors that may affect the appropriate level of service. These age/gender–based preventive codes (and whether the patient is new or established) are the standard way to accurately reflect a preventive visit. Documentation should clearly note the patient’s age, gender, and any risk factors to support the chosen code. If there’s risk-factor counseling or reduction performed, you can add the corresponding counseling codes as appropriate. Using a general E/M code or relying on diagnostic codes only does not properly capture a preventive service.