Wiki carve out

[codecrazy]

How do you carve out a office visit for a discovered problem when the patient was orginally just coming in for a physicial?

 

[LindaEV]

This is really subjective...first I consider the problem...and if it really took extra time...did it really go "above and beyond"? If at this point I think maybe, I make a copy of the documentation and cross out everything that would belong to the preventative coding. Whatever is left I use to audit for a separate e/m code. At this point there is either enough to justify an extra charge, or there's not. Ideally, there really should be a separate note! I find the "extra" work, is really not that extra...especially if it is a finding as a result of the exam.

 

[kamkole]

We struggle to determine what part of the exam would be considered "preventive" and what part would be "sick". An example would be a 35 year old male coming in for a preventive visit, but also has hypertension and diabetes. A hypertension exam is pretty detailed, but so is a preventive. Thank you!