Follow best practices to meet annual exam documentation requirements. By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, CSCG, AAPC Fellow Unlike other evaluation and management (E/M) services in the CPT® codebook, preventive services do not have specific documentation guidelines required to support the service provided. Here’s what you should know to ensure documentation supports ...
In Billing
Mar 9th, 2015
Sometimes, at a scheduled preventive visit, the patient mentions a new or worsened condition. If the patient complaint requires additional workup, beyond that usually associated with the preventive service, you may choose to report a problem-focused visit in addition to the preventive service. The CPT® codebook instructs: If an abnormality is encountered or a preexisting ...
In Billing
Dec 2nd, 2013
You must always match preventive medicine codes with a V code, even for Medicare patients. A preventive medicine service is not a problem-oriented visit. Instead of signs and symptoms or other “problem” diagnoses, use an ICD-9 code that supports the services provided (e.g., V70.0 Routine general medical examination at a health care facility for adults; ...
In Billing
Oct 1st, 2013
Danger is imminent if the chief complaint and unique documentation don’t support separately billed services. An example of so-called “split billing” is when the provider performs a physical exam and also discusses the patient’s chronic pre-existing conditions, linking the chronic diagnosis codes to the office visit and the reason for the visit (V70.0 Routine general ...