Wiki Annual Wellness Exam

[jvandyke]

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]

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.

 

[OpenClaims]

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?

No, each E/M will not need separate notes, however you do need to be able to distinguish that the reasoning for the separate E/M is profound enough to support itself. In addition, I always remind people to make sure that the provider is documenting everything necessary in order to bill an AWV. I often see pieces of AWV's missing.