Well-Woman Visit Billing: Preventive vs. Problem-Focused E&M, Modifier -25, and Commonly Missed Revenue

The well-woman visit is the most common encounter in an OB/GYN practice — and one of the most consistently under-coded. The pattern is predictable: a patient comes in for an “annual exam,” brings up two or three chronic concerns during the visit, and the provider documents everything in a single note. The billing team picks the preventive E&M code, the chronic concerns evaporate from the claim, and the practice loses $80–$150 per visit in unbilled problem-focused E&M.

Multiply that across 1,500+ well-woman visits per year in a busy OB/GYN practice and the unbilled revenue runs $120,000–$225,000 annually. None of it is fraud, exaggeration, or aggressive billing — it’s revenue the practice already earned and documented but didn’t capture on the claim.

This guide walks through how AMS Solutions’ AAPC-certified team handles well-woman billing — preventive E&M code selection, problem-focused split billing, modifier -25 documentation, and the workflow that captures both halves of the encounter when both halves are documented.

The Preventive E&M Code Family

For non-Medicare patients, well-woman visits use the preventive E&M codes (99381–99397), organized by patient age and whether the patient is new or established (Medicare practices follow a parallel G0438/G0439 path — see our AWV vs Annual Physical coding guide):

New Patient (99381–99387):

• 99381 — Under 1 year
• 99382 — 1–4 years
• 99383 — 5–11 years
• 99384 — 12–17 years
• 99385 — 18–39 years
• 99386 — 40–64 years
• 99387 — 65+ years

Established Patient (99391–99397):

• 99391 — Under 1 year
• 99392 — 1–4 years
• 99393 — 5–11 years
• 99394 — 12–17 years
• 99395 — 18–39 years
• 99396 — 40–64 years
• 99397 — 65+ years

For most adult OB/GYN well-woman visits, you’re billing 99385 (new) or 99395 (established) for women 18–39, and 99386 (new) or 99396 (established) for women 40–64.

What’s Included in a Preventive E&M

The preventive E&M code includes:

• Comprehensive history (age- and gender-appropriate)
• Comprehensive examination (age-appropriate, gynecologic for women)
• Counseling/anticipatory guidance/risk-factor reduction interventions
• Ordering of appropriate immunizations, laboratory, and diagnostic procedures
• Routine pelvic and breast exam (no separate codes needed)

The pap collection itself is included in the preventive E&M when collected by the provider. Some payers want a separate code for the lab interpretation, but the collection at the visit is bundled.

Screenings ordered (mammogram, colonoscopy, bone density, etc.) are bundled — the order is part of the preventive visit. The patient’s actual mammogram is billed separately by the imaging facility.

What’s NOT Included — Billable Separately

This is where the revenue lives. These services performed at the same visit are billable separately:

• Problem-focused E&M for any non-preventive concern (hypertension, depression, perimenopausal symptoms, etc.) — bill 99213/99214 with modifier -25
• IUD insertion or removal — bill 58300/58301 with the device J-code
• Endometrial biopsy (58100) when indicated for symptoms
• Colposcopy (57452–57461) when pap shows abnormality
• Cervical cryotherapy or LEEP when treatment is indicated
• Implant insertion (Nexplanon, etc.)
• Bartholin gland procedures
• Injections (Depo-Provera, etc.)

The Modifier -25 Split-Billing Workflow (see also our OB/GYN modifier cheat sheet)

When a patient comes in for “well-woman annual” and the visit covers both preventive components AND problem-focused work, the BOTH-billable structure is:

• Preventive E&M (99385/99395/etc.) — for the well-woman components
• Problem-focused E&M (99213/99214/99215) with modifier -25 — for the separately identifiable problem evaluation

The documentation requirements for the -25 to “stick” with payers:

Strong documentation (works): A note with two clear sections — first the annual well-woman exam (comprehensive history, comprehensive exam, pap collected, counseling), and SEPARATELY a problem evaluation (HPI specific to the problem, problem-relevant ROS and exam, decision-making, plan).

Weak documentation (won’t support -25): “Annual well-woman exam. Pelvic and breast normal. Pap collected. Patient reports heavy periods; will order CBC.” The problem evaluation is folded into the preventive note rather than separately documented.

The structural difference is that the strong example has a separately identifiable problem evaluation with its own HPI, ROS, exam findings, decision-making, and plan.

Common Well-Woman Denials

The five most common denial categories:

1. -25 missing when warranted (under-billing). Same-day E&M and preventive done; -25 not applied; problem-focused E&M lost. Not a denial — silent under-billing.
2. -25 used when documentation doesn’t support it (CO-50 or audit pull-back). Documentation didn’t separately identify the problem from the preventive components.
3. Age-code mismatch (CO-N822). 99385 billed for a patient over 40 (should be 99386).
4. Established billed as new (CO-N822). 99385 billed for a patient who had a well-woman in the practice within 3 years (should be 99395).
5. Pap collection coded separately (CO-97). Some practices try to bill Q0091 (pap collection) alongside the preventive E&M; many payers reject because pap collection is included in the preventive code.

Medicare Patients: Different Coding Path

For Medicare patients, the preventive E&M codes (99381–99397) are NOT covered. Medicare covers preventive services under:

• G0438 — Initial Annual Wellness Visit (once per lifetime)
• G0439 — Subsequent Annual Wellness Visit (annual)
• G0101 — Pelvic and breast examination (every 24 months for low-risk; annually for high-risk)
• Q0091 — Screening pap collection (annually for low-risk; every 11 months for high-risk)

For a Medicare well-woman visit, you’d bill G0438 or G0439 plus G0101 and Q0091. The non-Medicare preventive codes (99385–99397) WILL be denied for Medicare patients.

Workflow That Captures the Revenue

Three changes that capture the missed well-woman revenue:

1. Pre-visit intake question: “Are you here for your annual exam only, or do you have specific concerns to discuss today?” Identifies same-day problem encounters before the visit starts.
2. EHR template prompt: When provider documents preventive E&M, template asks “Any problem-focused work today?” — if yes, prompts for separate HPI/ROS/exam/plan section.
3. Pre-bill coder review: Quarterly audit of preventive E&M claims for missed -25 opportunities by comparing chart to claim.

These three changes typically recover a meaningful portion of missed well-woman revenue within the first quarter.

How AMS Solutions Handles Well-Woman Billing

AMS Solutions has been doing medical billing for OB/GYN since 1992. Our AAPC-certified team reviews every well-woman chart for missed -25 opportunities and applies the modifier with supporting documentation. Our Bespoke Team model means OB/GYN-trained coders work every claim — and we submit clean claims within 24 hours of charge entry.

When we onboard an OB/GYN practice, the first thing we do is a free practice audit of the last six months of well-woman visits — identifying every missed -25 opportunity, every age-code mismatch, and every misclassified new-vs-established encounter. For high-volume well-woman practices, the audit typically surfaces meaningful recoverable revenue across the preventive line.

Frequently Asked Questions

Where we work: AMS Solutions provides OB/GYN medical billing services nationwide, with active client practices including OB/GYN billing services in Ohio and OB/GYN billing services in Pennsylvania.