Question for those of you who are billing for preventative medicine services ( physical exams ) and also billing an additional E&M level for the same visit. Our facility has always done this, as long as the documentation supports it. Obviously, we have patient complaints that they shouldn't be billed for both. The Director of Revenue Cycles is curious if we "have" to bill for that additional E&M level? I think it is an unwise move to not bill for it as we are going to see a decrease in revenue, however, I am wondering if anybody has documentation on it being required. I know the CPT guidelines state the E&M "SHOULD" be billed in addition, but do we have to? It seems to me that if we were audited, we would be told we weren't billing correctly if we weren't using the additional E&M level when the documentation supported it. Any thoughts? I appreciate your help and your opinions