Question Annual Wellness Exam

jvandyke

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I know that an Annual Wellness exam and and E&M can be billed together with a 25 modifer.
My question is: Is separate documentation needed for each code?
 

vinessachilders

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You do not need separate encounter notes, but each service must have enough documentation to stand alone. For a wellness visit, documentation needs 10 ROS and a comprehensive physical exam, an assessment with the appropriate Z00.XX code, and any additional plan documentation as required (like Medicare's falls assessment, etc.); to bill an E&M in addition to wellness, the E&M needs a separate complaint, affected systems review, pertinent systems examined (if applicable, and cannot be counted towards wellness too), and MDM that supports the level billed.
 
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