Documentation for PREVENTIVE EXAMINATION\ ROUTINE EXAMNIATION

NishaJ

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Please anyone let me know,what documentation we need to bill preventive\routine examination for private payer. Is there any useful website, please share with me....
 

Chelle-Lynn

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General rules for documentation of apreventative examination are as follows:

· A comprehensive historyand physical exam findings;
o Past medical/surgical history (experiences withillnesses, hospital stays, operations, allergies, injuries, and treatments)
o Current medications and supplements
o Family history
o History of alcohol, tobacco, and illicit drug use, Diet; and Physical activities.
o Activities of daily living
o Vitals, height, weight, BMI, blood pressure
o Comprehensive review of system
o A full head to toe examination
· Adescription of the status of chronic, stable problems that are not “significantenough to require additional work”
o Notesconcerning the management of minor problems that do not require additionalwork;
· Documentation concerningage-appropriate counseling, screening labs, and tests
o Paps, breastexam, prostate exam, etc.
o Visionscreening, hearing screening, developmental
o Laboratorytesting, etc.
· Orders for vaccines appropriate for age and risk factors.
· Provide education and counseling as necessary
· Results of any testing


You can also check the requirements per your contract with the various carriers to ensure that you are meeting their specific requirements.

 

twizzle

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Bradenton, FL
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Preventive visits

I think the poster is asking for requirements for a regular private payer preventive visit 99385-99397 (age 18-65+). The requirements for children (99381-99394) are somewhat different.

Medicare's AWV is something completely different with very specific requirements.
 
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