Wiki Billing Annual and E/M Together


Portland, OR
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I need help. I need clarity on what is in the chart note that makes the difference of coding E/M with an Annual. I heard Annual is no hands on, just review and E/M is the physical exam. Our providers do hands on exam for all, so can someone help me with this? thank you for your assistance.
An annual exam does not mean that the physician is "hands-off" Part of the description of what encompasses a preventative/annual exam includes appropriate history, examination, counseling/anticipatory guidance/risk factor reduction intervention, ordering lab/rad, etc. The difference between an annual exam and a sick visit is the reason for visit and what is found during the course of the exam.

There are times when during the course of an annual or well check up, an abnormality is discovered. In that case you would follow the AMA guidelines for this scenario:

The extent and focus of the services will largely depend on the age of the patient. If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported