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Wiki Both preventive and E/M services in the same visit

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KoBee

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When a patient is seen for a physical or preventive/wellness visit, and also has acute complaints or chronic problems which require additional evaluation, there seem to be some confusion if should be billing for both services.



Patient presents for an Annual Wellness Visit (AWV). The patient has hypertension, which has been stable in the past, but upon examination they discovered that the patient’s blood pressure was elevated, and is no longer controlled, order of new lab work.

Is this enough to constitute a separate E/M from AWV?
 
It does. Depending on the extent of the service provided outside of the Annual Wellness this starts at a level 3/ 1 Uncontrolled Chronic Condition-HTN MDM- M/ L/ ? depends on what treatment plan is followed- Review and discuss current medication , add new script, adjust current script M + 99214-25

Enjoy
 
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