E/M vs Preventive Visit

LEE ANN

Networker
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45
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Patient states was only see for annual physical exam provider billed e/m with diagnosis. The CC & HPI both indicate patient was being seen for annual routine exam and the ROS and Exam portion also support this. Is it reasonable to code a routine physical Z00.00 even though the providers assessment is xxx - which is only mentioned in the patient's active conditions and not addressed anywhere else? Or would you query the provider to have amended assessment done adding the routine exam dx?
 

1formissy

Guru
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193
Location
Salem, Oregon
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On an audit perspective, because I have seen this before time and time again, the only way a provider can report an E/M in conjunction with a Wellness or Preventive Exam, is if that E/M is significantly separate and identifiable. If the patient has presenting problems that are addressed and a plan of care is documented, than an E/M would be supported separately. However, just simply saying Patient is here for wellness exam, or physical, is not sufficient in reporting a separate E/M.
 
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