Wiki New patient awv and e/m

[aaseals32]

Hi I have been trying to get a better understanding regarding awv and e/m ov billed together. This patient is new and dr coded 99385 and 99202. No additional workup was done for back pain so I was just going to bill the 99385 and wanted to know if that is correct.

Assessment
1. Encounter for preventive health examination (Z00.00)
Pt doing well overall.
Pt UTD on vaccinations
Pt UTD on pap smear
Recommend annual vision exams, dental exams, and consider dermatology appt in
future
Will check routine screening labs today
Encouraged pt to eat healthy, balanced meals, engage in regular exercise, and get
adequate sleep.
Depression screening performed
2. Chronic bilateral low back pain without sciatica (M54.50,G89.29)
Following with PT for chronic back and hip pain
Consider MRI/ortho in future for persistent issues
3. Chronic sinus complaints (R09.89)
Referral to ENT for further eval and management


Plan
 CBC, w/ Differential; Status:Active; Requested for:07Apr2023;
 CMP Complete Metabolic Profile; Status:Active; Requested for:07Apr2023;
 HEMOGLOBIN A1c WITH Eag; Status:Active; Requested for:07Apr2023;
 Lipid w/ Direct LDL; Status:Active; Requested for:07Apr2023;
 TSH w/rlfx to Free T4 - LC 349829, Q 6127, OR43562; Status:Active; Requested
for:07Apr2023;
15 min outside annual spent discussing back pain, sinus issues


Patient Plan/Instructions

F/u prn

Chief Complaint

CPE.

History of Present Illness

Pt here to re-establish care and CPE

Pt with chronic sinus issues
Recently had "sinus lift" surgery and reports daily sinus sx
Recently had dental surgery as well
No previous consultation with ENT

 

[TThivierge]

Hello AA,
Ensure your CPT code matches pt s age and if new or est. patient. So if pt new and between 18-39 yrs the CPT 99385 is ok. The dx Z00, M54.50, G89.29 (Chronic Pain) and block dx J32.9 instead of R09. since stated sinusitis. That s my take on info provided.
I hope helped you
Lady T

 

[Christal]

I would bill both the AWV and E/M. The MD has in his assessment the chronic sinusitis and to refer to an ENT. Regarding the chronic back pain he has mentioned about considering a MRI after follow of PT.

 

[csperoni]

I agree with billing both the AWV and E/M in this situation. The provider indicates a treatment plan for both the sinusitis and back pain, and that 15 minutes were spent separate and distinct from the AWV. In fact, I would consider the problem oriented E/M level 3.
I will note - this is carrier specific. There are some carriers that simply may not pay for both, regardless of -25 modifier due to their policy. Additionally, I don't think anyone will pay both visits as "new". Again, depending on the carrier, but this should probably be 99385, 99213-25. The problem oriented E/M occurred once the patient was already a patient.