Billing an annaul & E/M at the same time.

CindyWeems

Contributor
Local Chapter Officer
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10
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It is my understanding that the annual exam needs a complete past, family & social history. pt. also has a level 4 (99214) illness, how do you separate the history for the annual and the E/M code?
 

sdelth4284

Networker
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Location
Albuquerque, NM
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Instead of documenting two separate notes for a preventive care visit and an acute problem office visit our providers are allowed to document one note. The ROS will be complete and the Exam will be comprehensive to support the Prev Care visit. There will be overlap since the acute issue will be noted in the ROS and Exam as well. Due to this overlap our providers code the Prev Care visit, level the office visit, and then drop the office visit one level due to the overlap in documentation. A level 4 visit for the acute issue would be submitted as a level 3 visit along with the Prev Care code. This is an issue your department should discuss and create a plan for all to follow.
 
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