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

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