California Medical Association: Document carefully for same-day preventive, complaint-driven services

Often, a patient who arrives for a “preventive” service (i.e., a well patient exam) will also mention a problem or other health issue that he or she is experiencing. AAPC’s Managing Editor G. John Verhovshek, MA, CPC, recently published an article with the California Medical Association in which he expounded on the necessary elements behind reporting a problem-focused service in addition to the preventive visit.

“Documentation must support both services,” he says. “If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work may not be used to calculate the additional level of E/M service.”

Evaluation and Management – CEMC

Read the full article.

About Has 38 Posts

David Blackmer has been working in healthcare business operations and marketing since early 2008. He has authored and contributed to dozens of industry articles, and he is a regular speaker at various healthcare conferences and other events across the country. He earned his Master of Strategic Communication degree from Westminster College in Salt Lake City, UT.

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