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Initial Preventive Visit+ New Patient(CP)

veloso

Guru
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214
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I'm new to this clinic in fact their very first hired coder but, i have been a surgical coder only for 5 years.Now I'm assigned to audit each encounter through EMR and most of the physician doesn't know how to document and code for a split visit.They always put in their assessment V70.0 plus additional sick diagnosis code with preventive visit only.So,my dilemma is how it is documented in the progress notes which goes like this example:
HPI: First visit w/ the PCP needs PE.
GEN.ROS:Gen.appearance,etc,positive for chest pain intermittently for 3 mos.
and neg with the other ROS.
PSFH;Complete
EXAM;2-9 Elements
ASSESSMENT:V70.0;042;401.9 ;786.50
TREATMENT;LAB;VENIPUNCTURE;EKG
Pls.I really need your help on how to code for this encounter?:confused:
 

fredabrinson

True Blue
Local Chapter Officer
Messages
754
Location
Swainsboro/Statesboro, GA
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Your physicians are going to need to carve out the sick visit from the preventive visit. You also want to look for work up associated with the sick visit. If your physicians are only listing the diagnosis, but there is no documentation that additional work up or prescriptions were ordered for these other problems, it could just be part of the preventive visit.

You also want to look at the reason for the encounter; what brought the patient in. Was it just for the physical or did the patient have complaints, and were those complaints treated?
 
Messages
4,466
Location
Milwaukee WI
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0
Commercial

If the patient is NOT covered by Medicare, then rather than carve out the sick from the preventive, you may code both the preventive and office E/M ... based on clear documentation of both types of visit.

It sounds as if the documentation you have will not allow for this.

However, this particular documentation seems to me to have turned out to be a sick visit ... intermittent chest pain over 3 months (!)

Just because the patient needs an annual exam, doesn't mean that THIS visit was the preventive exam.

Good luck!

F Tessa Bartels, CPC, CEMC
 

veloso

Guru
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214
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Follow-up for prev.visit+sick visit

THANK YOU VERY MUCH FREDA AND BRENDA FOR YOUR IN-PUT.
CAN I BRING IT BACK TO THE PROVIDER AND ASKED HIM TO AMEND THE NOTES IN THE HPI BECAUSE AN EKG WAS DONE OR CAN THE EKG BE PAID WITH A PREVENTIVE CODE?AND DOES IT NEEDS MOD. 25 ON THE PREVENTIVE CODE?
AND PLS. I'M STILL CONFUSED WITH THE ELEMENTS OF THE EXAM ESPECIALLY FOR A 99204?WHICH GOES LIKE THIS:
VITALS;HR 66,BP 102/73,WT.152,BMI 20.05
GEN.APPEARANCE;ALERT AND ORIENTED,MALE THIN,NAD,SLOW GAIT,REQUIRING WALKER,PAUCITY OF SPEECH,POOR HISTORIAN,TAKES A FEW SECONDS TO ANSWER A QUESTION;HEENT;UNREMARKABLE,EOMI,TYMPHANIC MEMBRANES NORMAL,ANICTERIC SCLERA.ORAL CAVITY;CLEAR,MUCOSAMOIST,NORMAL TONGUE.NECK;SUPPLE,NO LYMPHADENOPATHY.HEART;NO MURMURS,REG.RATE AND RHYTHM.CHEST NORMAL SHAPE AND EXPANSION,CLEAR TO AUSCULATION,SYMMETRICAL.LUNGS;CLEAR TO AUSCULATION BILATERALLY,NO WHEEZES/RHONCHI/RALES.ABDOMEN;SOFT,NT/ND,BS PRESENT,NO MASSES PALPATED,NO HEPATOSPLENOMEGALY,WELLHEALED APPENDECTOMY SACR BUT ALSO WELL-HEALED VERTICAL ABDOMINAL SACR-PT REPORTS RUPTURE APPENDIX-LAPAROTOMY?NEUROLOGIC EXAM;NON-FOCAL EXAM,ALERT ORIENTED x3,CN'SII-XII GROSSLY INTACT,GAIT NORMAL,NORMAL STRENGTH,TONE AND REFLEXES,ORIENTED X3.SKIN;NORMAL NO,RASH.EXTREMITIES;NOCLUBBING,NOEDEMA,NO CYANOSIS,MUSCLE WASTING.PERIPHERAL PULSES;NORMAL (2+)BILATERALLY;LYMPH NODES;NORMAL
DO I HAVE 18 ELEMENTS FOR 1997 GUIDELINES
 
Messages
4,466
Location
Milwaukee WI
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0
Comprehensive Exam

You have a comprehensive exam by 1995 guidelines.

For 1997 guidelines you need at least 2 bullets in each of 9 systems (this is not the same as 18 bullets)

You have more than 18 bullets, But you do not have at least 2 bullets in each of 9 systems.

Google 1997 E/M Guidelines and 1995 E/M guidelines and print these out.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

veloso

Guru
Messages
214
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0
You have a comprehensive exam by 1995 guidelines.

For 1997 guidelines you need at least 2 bullets in each of 9 systems (this is not the same as 18 bullets)

You have more than 18 bullets, But you do not have at least 2 bullets in each of 9 systems.

Google 1997 E/M Guidelines and 1995 E/M guidelines and print these out.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Thanks a lot, it helps me build my understanding between 1995 & 1997 guidelines
 
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