Wiki 99213 and 99396 ? How to document?


True Blue
Salt Lake City, UT
Best answers
So my doctor wants to bill out 99213 and a 99396 (preventative exam) together. However, there is NOTHING in the documentation that states that the patient has come in for a preventative exam. In order to correctly bill this out doesn't the physician need to state which parts of the exam are for the 99213 and which are for the 99396? If you know the correct way to bill this, please let me know. Thank you.
Some payers bill both these codes with 25 modifier to 99213 but there must be proper documentation for both the codes such as "patient here for an annual follow up" or "established follow up visit" etc...

Hope this helps,

Dr.Jemimah Crescentia,CPC.
Here is what CPT says:

"If an abnormality is encountered or a preexisting problem is addressed in teh process of performing this preventive medicien evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key componetsn of a probelm-oriented e/m service, thenteh appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 shoudl be added to the Office/Outpatient code"

It goes on to state this as well:

" an insignificant or trivial problem/abnormaility that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key componetns of a problem-oriented e/m service should not be reported"

The documentation should be clear, most providers will have 2 separate notes so not to cause confusion in the case of an audit but some providers will "lump" it all together, you ( or any auditor) must be able to pull out the physical exam of the physical/ sick visit ( without double dipping).