When a patient with stable chronic health care conditions (eg, asthma, diabetes) is seen for a preventive medicine visit, the International Classification of Diseases, Ninth Revision, Clinical Modification code V20.2 (routine infant or child health check) should be reported with the appropriate preventive medicine service code (99381–99395). Chronic conditions may be reported as secondary diagnoses. The presence of a chronic condition does not change a preventive medicine visit to a problem-oriented visit; nor does it unilaterally support a separate problem-oriented evaluation and management (E/M) service (99201–99215) with the well visit.

However, if the patient has an exacerbation of the chronic condition that is significant and requires additional work to perform the required key components (history, physical examination, and medical decision-making, or time) of a separately identifiable E/M service, a problem-oriented E/M code may also be reported in addition to the preventive medicine visit.

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