Documentation - HPI both indicate

LEE ANN

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If the CC & HPI both indicate pt was being seen for annual routine exam and the ROS and Exam portion also support this. Is it reasonable to code a routine physical even though the providers assessment is Hyperlipidemia? Or would you query the provider to have amended assessment done adding the routine exam dx?
 

CodingKing

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Was the Hyperlipidemia diagnosed during the visit ? Was it pre-existing? If pre-existing how much work was done to address it? You can still have a routine physical and have medical issues. Ignoring the Excludes1 debate when it comes to well visits with sick visits under ICD-10, per CPT, unless its a significant additional effort above and beyond what would be done during a routine physical, it can still be coded as a physical.
 
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The preventive E/M visit with a problem-oriented service

When a patient comes into the office for a routine preventive examination and also has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a combination of preventive and problem-oriented care. As long as the problem-oriented service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam and the appropriate office visit code (99201-99215) with modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” attached to the problem-oriented service. It’s also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services. (See the example of a preventive E/M visit with a problem-oriented service above, and for more on ICD-9 codes, see “Using diagnostic codes effectively” on page 54.)
Note that the work associated with performing the history, examination and medical decision making for the problem oriented E/M service will likely overlap those performed as part of the comprehensive preventive service to a certain extent. Therefore, the E/M code reported for the problem-oriented service should be based on the additional work performed by the physician to evaluate that problem. An insignificant or trivial problem or abnormality that does not require performance of these key components should not be reported separately from the preventive medicine service. Reporting both preventive and problem oriented services on the same date can often lead to inconsistent results. While some payers will reimburse the full allowable amount for both the problem-oriented E/M code and the preventive medicine services code, some will assess a co-pay for each service, some will carve out the reimbursement for the problem-oriented E/M service from the payment for the preventive exam (which results in a total charge that does not exceed that of a comprehensive preventive examination alone), and some will simply deny the claim on the basis that they do not accept coding for both a preventive and problem oriented service on the same date regardless of the amount of the charge because, they say, you’re billing twice for the portions of the preventive and problem-oriented services that overlap.

http://www.aafp.org/fpm/2004/0400/p49.html
 
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